Better integrating services around citizens needs is a no brainer. So why is it so difficult?
The five year NHS plan, unveiled last week by my former Downing Street colleague Simon Stevens, has been widely and justly praised. The plan is based on robust arguments and contains many good ideas but, for me, its greatest strength lies in method: Rather than proposing a new national structure, or getting too involved in the detail of policy, it advocates a number of ways to achieve better integration of primary, acute and community care. Local health commissioners and providers are encouraged to consider which model best suits their circumstances while NHS England will focus on providing advice, insight and support for local reform. This enabling, decentralising framework is very welcome and one can only hope that other parts of Whitehall will emulate it.
But I have a major reservation. A key theme of the report is care integration; vertical, horizontal or both. This echoes a recurrent theme in debate not just in health reform but across the public sector. In 1997, for example, Labour said its top priority for Whitehall reform was to produce joined up government. Geoff Mulgan who was given the task of promoting more integrated working has described the rapid and profound disillusionment among civil servants as they saw the behaviour of Labour cabinet members continuously undermine the principles of joining up.
When something has been advocated so often and for so long, yet seems so hard to achieve in practice, we need to ask why.
The case for integration sometimes starts on shaky conceptual grounds. A truly comprehensive Whitehall approach to a major policy goal – like child poverty for example – would involve most major domestic policy departments. But while for some, such as DWP or Education, it would be a key priority, for others, such as the Ministry of Justice or DCLG, it would inevitably be more peripheral. In a complex system full integration of all factors affecting an outcome is virtually impossible. The NHS plan makes the case for health and social care services working better together but says relatively little about areas like housing and employment which are arguably just as important to public health and community resilience.
Just as full integration is impossible at a system level, it is also unlikely at an organisational level. Advocates of integrated solutions are often guilty of the merger illusion, namely that putting functions together in the same organisation is sufficient to make sectionalism subside. But as anyone who works in a large organisation will attest, the fact that managers share the same employer and use the same front door is pretty much irrelevant to whether they put corporate, customer-focussed interests above departmental, producerist ones. Team size is more important than organisational label, which is why some organisational theorists argue that the most productive and creative model of organisations is always to devolve to cross cutting units of around ten to twenty people. Strong integrated, outcome-focussed teams are needed to overcome the natural pull of professional loyalty and hierarchical incentives.
Indeed the three powers framework I advocated in my annual lecture two years ago (itself derived from cultural theory) provides a good basic checklist: Individual incentives, team loyalty and values, and hierarchical authority must all reinforce a shift to integrated working. Often the call from integration comes from the top while individual incentives and day to day loyalties continue to be oriented around functional specialisms.
A shared mission, robust systems and aligned incentives are all vital to the success of integrated models but there is also an important psychological and interpersonal dimension.
I have been working recently with a London local authority trying to join up employment services. Facilitating the meetings, I have been struck by the importance to the process of openness and generosity. In the last event I used the simple device of asking people in the room directly to request help from someone else. Eventually a manager from an agency focussed on employment told a local authority officer that the council’s welfare rights team often helped people increase their benefit entitlement while reducing incentives to work; ‘I know this is their job’ she said; ‘but given how bad long term unemployment is for people, shouldn’t they be focussing more on showing clients how they could be better off in work?’. The local authority officer was impressed and promised there and then that the welfare team would be given a much stronger employability mandate. From this point of discussion, it became easier for people to open up, talk about how they needed help and to start to offer help to others. Yet still I had to confront one senior manager who seemed to find it impossible – despite the evidence – to admit her service was anything but perfect.
Ironically, a problem with the call for integration may be precisely that it sounds so much like common sense. This leads decision makers and managers to underestimate the major and inherent barriers. A failure to perceive and act holistically is a very human flaw as is the tendency to act tribally and respond to immediate incentives.
Organisational reform may be a necessary condition for integration but, without attending to the psychological and cultural dimensions of what is an inherently challenging human process, such reform will not succeed in putting the joined up needs of citizens first.