Local health systems: Relationships not structure (April 2022)

Summary

Looking at health and care through a systems lens reveals a wealth of connections and opportunities to achieve better outcomes, as seen in the case studies within this paper. Systems are also complex and changing, with multiple inputs and feedback loops, and control distributed across multiple stakeholders. This paper is a timely exploration of the strategies, skills, and toolkit for effective working within systems. The paper is particularly focused on local government’s role in health and care systems, though there are learning points relevant to any systems leader.

Content

Recommendations

• Make sure that all partners’ strategic documents are aligned across the system. Strategic priorities and the documents that are set out to govern how organisations collaborate are crucial. They are not the end point, but along with trust and transparency in conversations between partners, these documents can be the basis of system-wide change. Getting the strategy right and making sure it is aligned is essential.
• Work closely with citizens. The shift from structures to relationships should go hand in hand with a shift from services to people. The population should be the starting point. Listening to citizens is also a crucial tool for understanding the impact that interventions have across the public realm. They can provide crucial evidence for or against policy decisions, and direct experience of how different parts of the system connect, or how they don’t.
• Balance risk. It is important for commissioners to develop the right balance between risk aversion and risk acceptance. There can be good reasons for risk aversion, particularly as councils often cannot afford mitigation, or there may be strong evidence against risk. Yet this should be balanced with the need to try new approaches and to collaborate with partners, which can present the risk of getting things wrong.
• Create the conditions for behaviour change. We often talk about behaviour change being the solution to many policy problems. But it won’t happen by itself. Within organisations, such as local authorities, leaders need to provide the right framework and incentives for staff to behave in certain ways. They need to create the conditions for trust and collaboration, aligning incentives and performance indicators accordingly so that staff feel safe enough to look around them, taking a system-wide view of the work that they do. This also requires a set of skills that may not be widespread or recognised, such as listening.
• System-wide budgeting. Funding should be provided specifically for the coordination of strategic priorities across the system. Various models of single pot place-based financing, going back to Total Place, have been tried and shown to have positive impacts.
• Build capacity. Capacity is already stretched in local government and in the NHS. Additional responsibilities for long-term strategy and partnership building should not impose greater demand on local authorities without decent and reliable support. System change cannot be done on a shoestring.