Results of implementation 1

Introduction

The aims and objectives of implementation 1 are detailed in Chapter 5. When these objectives were formulated, we assumed that the commissioning of the SICP would be stable over time, and that it would be possible to trace links between commissioning, overall project governance and outcomes. We intended to use a realist framework to structure the research,47,135 exploring contexts and mechanisms that appeared to support outcomes. However, in practice, the local and national commissioning context has been rapidly changing throughout the study, making it difficult to locate stable elements in the commissioning of the programme.

A number of national and local policy changes are relevant here. Local health-care organisations had an opportunity in 2014 to apply to be vanguard sites, which provided additional funding to test new ways of providing services. Salford took advantage of this, becoming a vanguard site in 2015. This brought with it new funding, new requirements for reporting and accountability and catalysed the expansion of the programme into integrated care for adults, including several service transformation plans and the establishment of an integrated care organisation (ICO). In addition, organisations within Greater Manchester took on a degree of devolved responsibility for health and social care, adding a new layer of local governance and rapidly evolving organisational structures.136,137 These changes will be discussed in more detail in the rest of this chapter, but of relevance here is their impact on the original intention to pursue a realist approach. In the realist methodology, researchers define and refine programme theories about the contexts and mechanisms by which policy programmes have an effect. However, the rapid evolution of the commissioning context identified above made it impossible to identify any stable contextual conditions or mechanisms relating to the commissioning of the SICP. As each element of the programme was explored, and candidate mechanisms identified, the context changed, with new structures, governance procedures and commissioning mechanisms. Furthermore, we found little clear linkage between the commissioning, governance and oversight of the programme and the actual activity on the ground, with the three SICP mechanisms of integration continuing to be rolled out in ways that appeared to be little affected by higher-level organisational and governance changes. Seeking linkage between mechanisms and outcomes was therefore not fruitful.

Finally, realist evaluation seeks to identify local programme theories underlying change programmes before exploring in depth the contexts and mechanisms. This assumes that, once identified, programme theories remain relatively fixed, with deeper exploration aimed at identifying new mechanisms or clarifying contexts, with the final outcome being a modification or clarification of how and why the programme theory applies or does not apply. In applying this framework to our case we suggest that the development of the ICO was in fact underpinned by an entirely different programme theory than the SICP. The ‘decoupling’ that we identified between the commissioning and the implementation of the programme may stem from this change in underpinning theory. Together, these three factors rendered the realist evaluation approach unhelpful and have made it difficult to draw clear conclusions about the impact of the commissioning of the programme.

In this chapter, therefore, we start by providing a descriptive account of the changes affecting SICP commissioning and management, including the development and implementation of the SICP, the development of the ICO and the latest move towards an integrated care system (ICS). We provide an account of the programme-level factors that facilitated introduction of the SICP and its maintenance over time. We structure this with reference to the factors supporting large-scale health system change.44,138 We then provide a brief account of evidence relevant to our original study objectives and finish by discussing the wider implications.

Section 1: commissioning and programme governance

Early development of programme commissioning and governance

Understanding the commissioning and funding of the SICP is not straightforward, as the programme was implemented and developed in a changing policy context. However, there are two core commissioning processes underlying the SICP: (1) national Section 75 funding and the associated Better Care Fund (BCF) and (2) the local Alliance Agreement.

Since 2006, local authorities and NHS commissioners have been able to pool aspects of their budgets to support joint initiatives, under Section 75 of the National Health Service Act 2006. Historically, these initiatives have been small scale (e.g. focused on joint commissioning for children with learning difficulties). Generally known as ‘Section 75 funding’, this continues to be the statutory underpinning for the funding of the SICP and the developing ICS.

In order to promote greater integration, in 2013 the Department of Health and Social Care announced the BCF,139 an ongoing national programme available to local authorities and NHS commissioners to jointly plan and deliver integrated services, with an initial intention that £3.8B of health and social care funding would be pooled from April 2015. The BCF did not introduce any new legislation; Section 75 remained the statutory mechanism. Local health commissioners were required to identify elements of their existing budgets to pool with local authority budgets. It was assumed by policy-makers that the costs of integrated services would be covered by the savings generated by a reduction in hospital admissions.

The BCF was announced after the start of the SICP. The SICP commissioning partners (CCG and council) had already agreed to pool £98M under Section 75. The BCF process (compulsory for all CCGs and local authorities) required them to submit plans to NHS England and the Local Government Association.

In response, the CCG identified £20M of its £98M pooled budget as its BCF contribution. There were problems with the BCF application, locally and nationally.139 Locally, the situation was complicated by the existence of the wider agreement to pool a larger budget. This meant retrofitting existing plans to fit BCF requirements and submitting further evidence to satisfy the national process. In addition, there were specific problems surrounding the expectations about estimated reductions in hospital use:

We have been through the assurance process for the BCF; we have been approved with support. This is the second best rating. We have received a number of risk issues that we need to respond to by the end of November, several of them relate to each other. ID 6 spoke to the BCF and is working with the [S]ICP steering and finance steering group, the risks have now been reduced to 10. We are pleased that our plans to reduce emergency admissions have been accepted. Nationally they wanted to reduce emergency admissions by 3.5%, we put forward that we should reduce them by 1% locally. This suggestion looked like a sticking point but it has been accepted.

Taking the Section 75 and BCF funding together, the total SICP funding started out as £98M, rising to £112M in the financial year 2015/16. The CCG contributed two-thirds and the city council one-third. Before agreements were made, a process of mapping was carried out between the council and CCG, focusing on current services for the health and social care in older people. They specifically looked at services that were in scope (at least 50% of the service had to contribute to the care of older people); any services that were deemed in scope had to be 100% within the programme to ensure that the governance arrangements were adequate. This Section 75 pooled budget arrangement was different from any previous historical budget sharing, as the operational management of the budget was governed by an Alliance Agreement, which included both commissioners and providers. The service provision included in the budget was:

• acute and community health via the foundation trust (£50M)
• care services provided or subcontracted by the city council (£30M)
• CCG expenditure including continuing health care and hospice (£10M)
• older people’s mental health services from the mental health trust (£8M).

Although the providers were not funding the SICP, contingencies for a partner organisation’s cost improvement programme were included within the contract. As part of the contract setting, providers had their contracts reduced through tariff arrangements, to ensure that they achieved cost reductions.

The traditional approach to commissioning involves a ‘commissioning cycle’: assessing population need, assessing current service availability and suitability, designing appropriate services to meet needs, assessing the availability of relevant providers and procuring the service, managing demand and monitoring performance (see http://commissioning.libraryservices.nhs.uk/commissioning-cycle; accessed 18 May 2018).

The SICP worked differently. It did not matter whether partners were commissioners or providers: both were equally involved in the decision-making:

I think it’s having a bit of faith and constantly when people raise that, just really assuring them that . . . and I can’t remember at the beginning how many times I said this is a partnership approach, it’s a partnership approach. Because people used to say things like oh well, it shouldn’t be Salford Royal dictating how that happens. Well, it isn’t Salford Royal, it’s a partnership and we’re in the room, we get listened to. And it was just constantly reassuring. And it was a different way of working actually, it wasn’t a commissioner led . . . and it was just constantly reminding people this isn’t commissioner led. It’s a partnership and we have to give and take and compromise.

In the early phases of the SICP, when contractual decisions were being made, providers were present as members of the Alliance Board, and perceived as experts who can offer useful information, even when the service being discussed was to be provided by a different organisation. This dynamic shifted the balance of the commissioning process:

Then we’ll have individual service contracts, so the CCG or the council will then go away and have contracts in place with the relevant provider organisation. Because it might not be Salford Royal or GMW [Greater Manchester West] that’s the provider. So GMW and provider when they’re in the room are from the alliance perspective, are giving their expert opinion in terms of what will work and how we will deliver the model to achieve the outcomes, not as an organisation we can do that and we want the contract to deliver that. Some instances they will have the contract, in other instances they won’t have the contract.

Alliance Agreement

In addition to Section 75, the SICP was also underpinned by an Alliance Agreement. This outlined how decisions were made and the governance mechanisms which applied. The document articulated how the organisations would work together as a system of both commissioners and providers. Although sometimes referred to as the ‘Alliance Contract’, it was technically not a contract, as the provisions were not specific enough to be legally enforceable:

I mean if anything on reflection I think the Alliance Contract is about publicly saying, we’re going to work together. Contractually in blunt terms it’s probably not worth the paper it’s written on, if you know what I mean? It’s the principle of it.

The document can be seen as a set of guidelines for behaviour. The document outlined the terms of the agreement (initially 3 years 5 months, with the option for a further 3 years). Such an extension would have to be agreed by all parties (except the general practice provider). The agreement included provision for an annual review, which was intended to ensure that the SICP was delivering its objectives. The Alliance Agreement was not a definitive document; many issues remained to be clarified and it simply set out the process by which such decisions will be made in the future. For example, clause 15 outlined that a framework for risk and benefit sharing needed to be developed. Timelines were included, highlighting when tasks needed to be carried out, but these lacked specificity about who should performing those roles. Furthermore, the document lacked specificity in terms of situations in which conflicts or disagreements may have arisen. The Alliance Agreement proposed a risk and benefit sharing framework, which would outline procedures if the pooled budget faced either an over- or under-spend (Alliance Agreement, internal report).

It was acknowledged that it was impossible to prespecify all possible future scenarios, with the Alliance Board seen as the forum in which any problems would be discussed:

. . . and the reality is, when issues do arise, the situation for each one is different and the factors for creating is different. So the Alliance Board use a forum for those conversations.

Overall, the agreement could be seen as an agreement to agree at some point in the future, rather than an actual contract. The most specific aspect of the agreement was the scheme of delegation for decision-making (see Appendix 4, Table 61), which clearly defined what decisions could be made within the structure of the SICP without each decision having to be taken back to each partner organisation.

Alongside the Alliance Agreement, there was a detailed ‘service and financial plan’, which provided a breakdown of the pooled budget, with additional detail regarding the investment and disinvestment of services, BCF plans and the general models for implementation.

Although not a legal contract, respondents stated that the process of developing the agreement had been as important in supporting the early development of the programme as the details of the agreement itself. Simply knowing that there was a formal process of sign-up, with clear governance processes, allowed the key organisations to feel secure in decision-making. Presenting the details in the form of an Alliance Agreement made their declarations ‘official’ and provided legitimacy. The process of developing the Alliance Agreement allowed the key stakeholder organisations time and resources to think about what they wanted to achieve, outlining risks and benefits for the organisations:

But the benefit of the Alliance Agreement was primarily the process we went through to agree it. It was refining a shared vision. It was having the difficult conversations about, you know, what are our anxieties, what do we want to achieve. It codified the things we were setting out to do and our expectations of each other.

Furthermore, individuals stated that part of the value of the contract was that the act of signing a document makes the stakeholder organisations more likely to work through issues when disagreements arose:

So it’s a big deal, you know, you sort of owe the other stakeholders once you’ve agreed this. Because people will walk away without any of that control, they always have, and will do. So hence there has to be an overbearing focus on governance, it dominates everything.

During the period in which the Alliance Agreement was in place, no significant conflicts or disagreements arose. Therefore, the Alliance Agreement arrangement was never tested. It was acknowledged that, in part, this was because a financial buffer had been put in place, limiting the financial risk:

Yeah, so there was some slippage created and that balanced it out last year and then a couple of other things happened this year, so they knew that they’d got underspend within the Alliance budget . . .

Towards an integrated care organisation

Not long after the SICP was established, moves began towards a formal ICO (mooted in CCG documents from July 2014). This would achieve two things:

1. move beyond the ‘partnership’ model underpinning the SICP, moving staff from the council social care team into the foundation trust alongside community services colleagues
2. extend the population covered to all adults.

The logic underlying this was not clear. In interviews, respondents simply characterised this as ‘the obvious next step’, without clearly explaining why:

I mean, obviously, one of the things that we’ve got to do in terms of the programme, I mean, we’ve moved onto the ICO rather than the integrated care programme but it makes sense because it’s the next step really.

This respondent spoke of greater ‘efficiency’, without clarifying what this might mean and how it might be achieved:

The agreement that was reached as the system was that the ICO itself needs to have benefits in and of itself, so it has to be more efficient to have more people together, so having social workers working in the same teams employed by the same body as district nurses, has to be more efficient. You have to be able to reduce some duplication etc., so the ICO has a target for efficiency. It comes as a result of bringing staff closer together.

An ‘outline case’ briefing document was used internally to provide information for those involved in discussions about the ICO (Box 2). This document set out the advantages of integrated care and suggested that a more formal integrated organisation could overcome deficiencies in the partnership model:

4.6: although care can be integrated without creating an ICO, the advantage of this approach is that a single organisation with one funding envelope, a single set of goals and one vision for Salford’s health and social care economy is able to avoid many of the problems of fragmentation experienced in virtually integrated systems.

4.7: those areas that have sought to integrate services without some form of structural or functional integration have frequently experienced a number of difficulties in making integration ‘stick’. There typically include:

• inability to align service delivery ‘on the ground’
• organisational and professional silos
• inconsistent operational procedures and policies
• fragment information technology, information and reporting systems
• different approaches to managing performance, risk and governance.

However, no evidence was forthcoming about the existence of these problems in Salford. Indeed, interviews with senior leaders in all organisations had emphasised the strength of the partnership model. The focus appeared to be on anticipating and preventing future problems. Thus, at an engagement event to promote the ICO idea, the focus was on the ICO as an obvious step in order to cement the gains made to date:

We are motivated by success and we have a really strong shared vision for the future. We want to harness what we have got and maximise benefits. All the main organisations have agreed to go a step further so that we can deliver services to all adults in an integrated way; integration will be delivered by an ICO or a lead provider organisation. This is a really big step and change but we will be working with the same outlines as we did for older people. Our vision is to deliver care in a different way, centred on individual needs to maximise the benefits.

During interviews, individuals were asked what the ICO could offer that the SICP could not, especially as the programmes of work were essentially unchanged, other than expanded age coverage. The ICO was described as a structural mechanism enabling the transformation that the SICP was trying to deliver:

It’s structural [ICO] . . . by structural I mean employment, legal, etc. The integrated care programme is about transformation, so it’s about doing things differently . . . setting up a preventative way of working, supporting people to support themselves, etc., so clear goals and aims and all the rest of it. The ICO is an enabler to that, so by bringing staff together by removing barriers, by having one team Salford, it would be easier then to transform the work what we do, to deliver the goals of the [S]ICP.

The SICP and ICO were not described as separate entities. Instead, the SICP was perceived to outline the strategy for the programme of work, whereas the ICO has been introduced as a mechanism to deliver the strategy:

. . . but the programme I suppose is a strategy and the ICO is actually the operational delivery, I suppose that’s one way, but they kind of knit it together, they’re not two distinct entities, if you like.

The ICO was described as a way of providing a single leadership structure, which provided the co-ordination of services and reduces fragmentation. Although partnership working was perceived to be good locally, the single leadership structure of the ICO was an opportunity to better co-ordinate care. The ICO was identified as a means to examine care pathways more closely to ensure that there was one service for patients:

That’s four different hand-offs along a pathway. You know, it enables Salford Royal to look at it and go, d’you know what, it makes sense to have one service. People’s experiences is one experience, so . . .

One possible explanation for the decision to establish the ICO lay in the broader NHS. In 2014, NHS England published its Five year Forward View.140 Central was a call for NHS and social care organisations to develop ‘new models of care’.

Five new models were proposed:

1. primary and acute care systems (PACS), bringing together acute hospitals with primary, community and social care providers
2. multispecialty community providers (MCPs), in which all types of community providers work together with their social care counterparts
3. extended care in care homes, in which local primary and community care providers work together with private- and council-funded care homes to improve care for patients
4. urgent and emergency care, in which different combinations of providers work together across a geographical area to rationalise and improve urgent and emergency care
5. acute care systems, in which providers of acute care work together to rationalise and improve provision of more specialised services.

Volunteer groups of providers (designated as ‘vanguards’) were invited to come forward to test these ‘new care models’, and would be provided with additional funding and support.

This provided an opportunity for the SICP, as national policy supported existing local plans. There had already been discussions about how the SICP could be extended and the model embodied in the SICP (close collaboration between a foundation trust, CCG, general practice providers, and the local authority commissioners and providers of social care) already met many PACS requirements. As the vanguard was aligned with existing local plans, linkage would offer additional financial support, as well as access to a network of providers undertaking a similar journey.

A second motivation lay in the more general environment for large providers. A 2014 review of provider activity and development for the Department of Health and Social Care141 highlighted both the need for innovation in the provision of care and the need for a facilitative regulative structure at national-level supporting providers looking to innovate. The report advocated allowing innovative providers to move ahead rapidly, with light touch regulation and support. The development of ICOs was one of the innovations advocated. The opportunity to be seen as at the leading edge of developments was attractive.

Thus, 2015 saw the introduction of a PACS vanguard with an intention to integrate primary and acute care systems, joining up general practice, hospital, community, social care and mental health services for adults. The ICO was to be established as the ‘prime provider’ of services across Salford, bringing the adult services provider arm of the city council into the foundation trust and subcontracting with other providers (such as non-specialist services at the main mental health trust) for a range of services.

The application set out what the vanguard hoped to achieve, building on the ‘successful’ elements of the SICP, aligned to a federated model of general practice. As discussed above, the ICO/vanguard included the transfer of adult social care from the city council to foundation trust, including the contracts for adult social care homes and domiciliary care. Furthermore, the contract for mental health services for adults and older people was also transferred to the foundation trust, which could be subcontracted to the mental health trust.

The practical issues associated with ICO set up were considerable. The aim was to bring together local adult health, social, mental health and acute care into one place, underpinned by a single health and social care contract for the ICO. For the foundation trust to take on this new role, a large number of staff moved across from council to trust under Transfer of Undertakings in Public Employment (TUPE) legislation:

We’ve been working on what we call an ‘on-boarding process’, so to welcome 400 people into the new organisation, they have to learn new systems for time recording, sequence recording – all sorts of things – e-learning. But that’s just the practical side of things . . . The other part of my role is around the business strategy side. I’ve been involved in the development of various legal agreements, contracts, and risk share agreements, which is hell of a lot of work, just to make sure that organisationally we understand the relationships for the future and there’s no barriers that could be created because we didn’t clearly articulate what the arrangement was, so . . . I think that’s quite a strength for Salford and has been for some time, that we’ve got a group of senior managers across the organisations that get together and think those agreements through in a very methodical way.

Integrated care organisation implementation was rhetorically designated as a ‘safe landing’. It was agreed by all stakeholders that, for the future success of the ICO, the initial phase was to implement the ICO, transfer staff across and take on the responsibility without initially making any changes to how people work and how services are delivered. The stakeholders wanted to continue to work in partnership and not produce additional risk:

. . . the phrase we use is, safe landing, so nothing should change. The people who are receiving services . . . nothing should change because there should be a smooth transition, so that we’re not creating any risk in the system, but having said that, it is obviously different as well, so you’ve got to get it right for staff and so on. It is a period of change and we’ve been really clear and all partners have agreed that, yeah it will take a few months for that to bed down, but everybody should sort of move in to their new roles if you like, but also we’re all still here, we’re all still a partnership.

Ongoing commissioning of integration: the ‘integrated care system’

As we have seen, the local and national policy context was constantly shifting, requiring those involved with integration services to adapt. The most recent change was the devolution of responsibility for health and social care to Greater Manchester in the devolution settlement.136 This required all boroughs to produce a locality plan, setting out how health and social care services will work together and providing an opportunity for leaders to develop an overarching narrative, which pulled all the various initiatives together into a coherent whole.

Leaders now talked about an ICS, which aimed to make sense of the changes that have occurred and generate organisational and public ‘buy-in’. The partnership underlying integrated care was rebadged, with the overall aim of improving the health of the population through integrated care. The vision was expressed in the concepts of ‘start well’, ‘live well’ (addressed by the ICO, focusing on the adult population) and ‘age well’ (addressed by the SICP, people > 65 years of age).

The ultimate aim of the ICS was to link general practice more closely with the other stakeholder organisations to deliver services in a neighbourhood model. This would involve general practices working more closely together to provide services across a geographical footprint covering 30,000–50,000 people. To facilitate this, a general practice provider organisation would bring practices together and form a single body with which the ICO could contract and interact. How this would work in practice, and what the relationship would be between general practices and the ICS, remained unclear.

To support these developments, new governance and contractual mechanisms have been required.

In our initial interviews, it was suggested that the Alliance Agreement would form the basis for the ongoing developments. However, once it had been decided to move towards an ICO, a new governance structure was necessary. The ICO formally came into being in July 2016. The new ICS was focused on the integration agenda for the whole of the adult population, which included the original SICP. The new pooled budget covered £246M of expenditure.

The areas of work for the adult population were said to be based on learning from the SICP and will continue to include the programmes of work (community assets, MDGs and ICCs). The focus of the adult population will be across several key priority areas including:

• vulnerable adults
• long-term conditions
• mental health (drug and alcohol dependency in particular)
• dementia
• mental and physical needs.

The aim of the ICS was to bridge a projected £6M financial gap over a 5-year period through service redesign. A new service and financial plan was devised for the whole adult population based on a pooled budget between CCG and council from 2016 to 2021. The budget included all adult social care, learning disabilities, community equipment, foundation trust hospital care, foundation trust community services, adult (non-specialist) mental care services (hospital and community), A&E, continuing health care and NHS funded care, and some CCG grants/contracts for non-NHS providers.

The plan for the ICS was developed in phases:

• Phase 1 – in March 2016, an initial review of the commissioning intentions within the older people’s financial plan was conducted.
• Phase 2 – in May/June 2016, a stocktake of the workstreams within the SICP was carried out, to set a clear work plan for 2016/17; pre-planned city council and CCG workstreams and service reviews were documented alongside the vanguard proposals.
• Phase 3 – the amalgamation of the workstreams above, outlining the outcomes of the plan, shared programme risks and the process by which the plan will be delivered and monitored.

For the ICS to operate, commissioning intentions across Salford have been consolidated over a number of workstreams. The consolidation included:

• older people’s service and financial plan 2014/15–2017/18
• existing or preplanned city council or CCG workstreams and reviews
• aspirations within Salford PACS (the vanguard application).

To oversee the ICS a new governance structure was developed to replace the Alliance Agreement and Alliance Board from June 2016 (see Appendix 4, Figure 13). There are now two new committees: (1) the Advisory Board for Integrated Care, which has a similar membership to the Alliance Board, bringing together commissioners and providers, and (2) an Integrated Adult Health and Care Commissioning Joint Committee (ICJC; see Appendix 4, Figure 14), which involved only commissioners. This was necessary to allow commissioners to make joint decisions about the pooled commissioning budget:

So it was felt to be more appropriate for us to move from an alliance of the two providers and two commissioners to the two commissioners making all the decisions about the pooled budget, the commissioning budget by agreeing a service and financial plan and keeping that as a commissioner only decision-making process . . . Now in reality there’s no way because of our history in Salford we would just go in a dark room and write that as commissioners and present it to the providers, it would still be an iterative process. So we’ve established two groups, there’s the decision-making board, which is a joint committee between the council and the CCG, and then there’s an Advisory Board which is quite similar to the old Alliance Board . . . But they do not have any decision-making. But if they felt really, really strongly about something it is going to have an influence on it, they might not be the decision-makers but it will have an influence. And if we reach a stage where we’ve got the Advisory Board saying one thing and the decision-makers say another then we’re in a bad place really so we have to sort that out.

The ICJC would oversee the pooled budget across the council and CCG, whereas the Advisory Board has responsibility for the additional investment that has been received from the devolved Greater Manchester transformation fund to support the vanguard.

Devolution added another layer of complexity. The first year of being a nationally designated vanguard saw additional funding to support the work. This was non-recurrent, intended to support ‘transformational’ activity by, for example, allowing investment in infrastructure or to support ‘double running’. In the second year, vanguards were required to submit a further value proposition, setting out what additional funding they required. However, the Greater Manchester Devolution Partnership had negotiated a transformation fund with the Treasury, and it was decided that Greater Manchester’s allocation of vanguard funding was included in this total. The rebidding process caused delays and complications, but, under the transformation fund, Salford accessed £18.2M over a 3-year period:

But because GM [Greater Manchester] has a 5-year funding pot, we were able to secure commitment for more than a single year. So we put forward an application, as I say, over 3 years, so we’ve got a 3-year investment plan, which matches with the 5-year disinvestment plan. And our ICO and the arrangements that we’re establishing, and this investment and disinvestment, makes a contribution to closing Salford locality plans projected funding gap.

However, ongoing funding depended on demonstrating impact:

We always have healthy debates here. We need to demonstrate that we are doing what we said or else GM will terminate the funding.

The contractual mechanism was a so-called ‘prime provider’ contract between commissioners and providers. This form was relatively new and untested in the NHS. A single large organisation is designated as the ‘prime provider’ for a range of services. This provider is then responsible for providing those services, either themselves, or by subcontracting with other providers. The foundation trust was the ‘prime provider’, with the scope of services covered including care for the entire adult population. Thus, the foundation trust will be contracted to provide acute and community care, subcontracting for mental health services. Under this contract, commissioners set the overall strategy and the prime provider was then responsible for service delivery within the specified budget, as well as the quality of subcontracted services. The contract will usually include a range of incentives and risk-sharing provisions. The original intention was that the foundation trust would also subcontract for some services provided by general practices, via a primary care provider organisation. However, this proved difficult.

General practice was an important strand in the initial vanguard plan:

The vision is that general practice, at a neighbourhood level, will collaborate and embrace all community-based health and social care services for a defined population. This includes other primary care based services; pharmacists, dentists and opticians, as well as community and voluntary organisations. It is expected that all care that doesn’t require hospital facilities will be based and managed in the neighbourhood and for pathways of care crossing into hospital to be better for patients. Personalised care planning will benefit from a multiprofessional approach, drawing in specialist expertise and resources as needed.

However, interviewees acknowledged that, in developing the ICO, less attention had been paid to engaging with primary care in the development of this vision. General practices, although engaged in the SICP via their participation in MDGs, remained largely detached from the broader ICO development:

So I think . . . well, some obviously GP practices no matter how often you try and talk to them they don’t really have time to listen, do they, really? They weren’t necessarily listening and then there were lots of misunderstanding about what we were doing and then jump to [conclusions] . . . and everything felt like two steps forward, one back and everything.

An intensive programme of engagement work was launched in spring 2015. Conducted by the CCG, the intention was to encourage member practices to become more involved with the integration agenda. Later, this included the appointment of an external consultant (January 2016), who engaged with local GPs. This engagement highlighted the lack of connection between the broader agenda of the ICS and the wider NHS, and the day-to-day reality of GPs’ working lives:

What was immediately clear is actually GPs were largely disengaged from most of the process that had been going on. So by that what I mean is actually most people were unable to articulate what a vanguard was, nearly everyone was unable to articulate what the ICO was. Very few people had heard of Five Year Forward Views and the like, and actually when you started to talk about the context of integration in general practice, most of the stuff that the GPs wanted to know was ‘is this going to relieve my workload, is this going to help me with my workforce’, and occasionally ‘is this going to help me with my premises, which is also under pressure.’. So, once again, it wasn’t that GPs were pulling against the idea of an ICO, it’s just it wasn’t relevant to their day jobs.

Summary: commissioning integrated care

As we have highlighted, the development of the SICP and the ICO fundamentally changed the relationship between commissioners and providers. Rather than commissioners identifying needs, specifying services to meet those needs and then procuring relevant services, commissioners and providers in Salford are working in partnership, co-designing services. This was clearly seen during the fieldwork; when observing the Alliance Board meetings, an observer would not be able to tell which participants are providers and which commissioners. The commissioners, any more than any other partner, do not set the terms of the discussion, and there is no ‘challenge’ from commissioners. Rather, the focus is on a partnership approach. This raises questions about the longer-term development of the commissioner role, as it seems likely that future service developments will be provider led. In addition, as a prime provider, the foundation trust will be commissioning and contracting for mental health services on behalf of the CCG, leading to potential longer-term complications around conflicts of interest:

There is the potential the SRFT [Salford Royal Foundation Trust] will change as they commission services as they will have different agendas, will the CCG pass on that infrastructure / resource? We need to be clear what the purpose of the CCG is. The CCG may choose to commission PC [primary care] and they still have an acute agenda, but for MH [mental health] this will be delegated to the ICO. There will be potential conflicts of interest with the roles of commissioning and providing. They need to be clear what the commissioning agenda is and what is the provider agenda is. This is difficult as there is an invisible wall where commissioning ends and providing starts. For example if in the future in the MDGs, SRFT feel that GMWFT [Greater Manchester West Foundation Trust] aren’t providing mental health to the standard they expect, they may challenge as a commissioner but then we could argue that there aren’t enough district nurses which is a problem for them as a provider.

Furthermore, the development of this strong partnership gave providers in the room some power over other (non-partner) providers locally. Contractual arrangements with these other providers were discussed at partnership meetings, and this could give foundation trusts an advantage. Although this can be viewed as potentially detrimental with regard to competition, it could also be argued that having the high-level people sitting around a table offers a forum in which commissioners and providers can have discussions beyond the SICP to bring about change, and that this may be more effective than competition as a means of improving services. For example, at one Alliance Board there was a need for the CCG to commission more beds at the trust:

We’ve invested in SR [Salford Royal] for 18-month contract for beds, etc. whilst the review is worked through. For community equipment we have supported the business case in principal, we need some more information. The good news is that this is major investment area for the programme.

When the ICO was in development there seemed to be a need to re-establish a distinction between the commissioner and provider roles. During interviews, key stakeholders were asked why the roles were being separated. It was explained that it was a request of the commissioners and was required if they would be working in a prime provider model.

I think there’s a lot going to one place, so I think commissioners needed a way of holding that to account, so I think that’s one thing. I think the second thing is that the city council’s obviously changing its role . . . moving from being a direct deliverer of services to being a commissioner of services, so I think the view was that was part of the process of allowing the city council to move into its new role of being a strategic commissioner.

The change in the relationship was described as a mechanism to clarify roles and responsibilities. However, the new arrangements do not override all of the partnership working that has been established:

So that’s slightly delineates responsibilities more, you know, it’s much clearer now. Salford Royal is responsible for making integrated care happen through a supply chain. And the commissioners have the responsibility for commissioning from Salford Royal as the prime provider, the range of integrated care services and outcomes that they want to achieve. That doesn’t mean that we’ve reverted to just a contractual relationship, you know, but that world exists in parallel – and I mean that in a good way – to one where we are sitting down as partners and debating what is it that we want to do.

During an observation of the Advisory Board there was an acknowledgement that there were a number of committees that were commissioner or provider only. However, the majority were still perceived to be following a partnership model of working:

There are other sources of finances separate from here. In terms of the governance, I think it is important that we are still all working in partnership other than a couple of committees.

The consequences of the new working relationships are unclear. However, observations of the workings of the Advisory Board suggested that the separation between the commissioners and providers has led to additional complexities being introduced into the structure of the partnership and the financing of specific projects. The Advisory Board has the decision-making responsibility for the non-recurrent investment funds allocated to the ICO from the transformation fund, whereas the ICJC will oversee the pooled recurrent budget across the council and CCG for the adult population. Although they are clearly separate ways of funding programmes of work, it was identified that some specific programmes of work will obtain funding from both budgets. This will impact on how and where decisions are made, underlining the need to tightly manage communication.

These complexities will arise in other vanguard sites as they establish new models of care. There is work being undertaken by the national team responsible for vanguard development to support them as they navigate the new relationships required. The test will most likely come if a prime provider fails to deliver the outcomes for which they are contracted.

At the onset of this research it was assumed that the commissioning of the programme would be stable, and that it would be possible to explore the relationship between SICP progress and success and the mechanisms used to commission it. In reality, partly owing to the ambitions of those leading the programme, and partly in response to conditions in the wider NHS, the commissioning and governance structures associated with integrated care were in constant flux. It is therefore very difficult to make links between programme commissioning and governance, the extent to which implementation has been successful and the achieved outcomes. Although the structures and governance of the SICP were changing in the fundamental ways, the work of the SICP has continued more or less unchanged. A ‘stocktake’ determined that there was as yet no evidence that the programme will meet the initial agreed targets (e.g. reduce hospital admissions), but no specific changes were suggested other than to continue with the ICO implementation.

In the next section we explore the factors that seem to have supported or inhibited setting up the SICP.

Section 2: understanding system change

As discussed in Chapter 3, a review of major health system change identified ‘five rules’, which support successful change;44 these were subsequently modified.138 Four of these modified rules of the greatest relevance to this chapter are set out in Table 25.

Rule 1: blend designated with distributed leadership

The SICP was strongly led from the top, including strong representation from senior managers on the Alliance Board. Furthermore, there had been stability among these managers. The foundation trust initially took an overall lead given the disestablishment of PCTs and creation of CCGs; as well as initially driving the agenda, it was also prepared to commit more resources.

Furthermore, senior leaders were prepared to commit significant amounts of time. Weekly meetings were held between key people involved with the development of the programme:

And I think one of the things I learnt from the programme is that momentum of meeting weekly, being really disciplined in doing the work and meeting weekly really started to pay off quite quickly, in that it really got the momentum going in that project . . . So it sounded really over the top to me, weekly, it really did. But I think as long as you don’t set yourself massive tasks during the intervals, or give yourself dates to do certain things.

At the same time, a robust management structure was also developed, with strong commitment from the middle management in partner organisations:

So we’ve got some executive and chief officer leadership, there’s some sort of second line reports beneath that level where there’s some dedicated time, and that’s largely about kind of the governance of the programme through the finance and steering group now. There’s a dedicated project team, and then we’ve got some operational capacity, so people in city council, in Salford Royal mostly, a little bit in GMW [Greater Manchester West] where we’ve released capacity, we’ve said, actually, this is really important to us . . .

This structure included a clear system of delegated decision-making. This was important in supporting the day-to-day running of the programme. Our interviews suggest that, in the early stages, close partnership working between senior leaders from both the commissioners and providers was important in deciding what the interventions should be and in getting the programme running. This was particularly important in the time and effort invested in developing the Alliance Agreement.

Working together to produce an agreement supported the partners in developing a trusting relationship, which in turn supported the development of the programme as a whole. Once implementation was under way, however, the focus of these senior leaders on the Alliance Board shifted towards the development of the ICO and the vanguard, leaving the middle-level managers to get on with the day-to-day tasks required to run the programme. The scheme of delegation allowed the middle tier of managers to operate with some freedom within the confines of their delegated authority, in keeping with the need to allow those below the most senior level of management to provide local leadership.44 The leadership for the integration agenda as a whole has remained the same throughout the development and implementation of the SICP, ICO and ICS. The same people representing the four key stakeholder organisations have been involved with the partnership, which has enabled trust and consistency to be developed. This has allowed individuals to carry out the work required of them, rather than working on establishing relationships and trust across the organisations.

Alongside this, the programme was set up with designated managerial time and support, further facilitating ‘distributed’ leadership. Thus, for example, initial work on the programme was carried out with support from an independent innovation and improvement centre.

Rule 2: establish feedback loops

‘Feedback loops’ about performance are an important determinant of success in large-scale change. However, although helpful, other tools to support behaviour change – such as financial incentives – may be important.138 The SICP was set up with clear performance goals, centring on reduction in admissions and the improvement in patient experience. The Alliance Board received regular reports about performance against these metrics. However, delays in establishing elements of the programme allowed those involved to develop a narrative which emphasised the longer-term nature of expected improvements:

. . . and what people have fed back to me is that it has taken longer than was anticipated to implement, . . . the point at which people say yes, this is up and running and people . . . it’s embedded, it’s become the way of doing things, you would then start to see something . . . some impact, so that’s . . . and I think from what I understand there are starting to be some initial . . . [impacts].

There were also concerns about the data that was being used to monitor the programme indicators:

Another measure, not a local measure but certainly it gets a lot of national attention and is one of the Better Care Fund measures is our delayed transfers of care. That has significantly reduced since we’ve been doing this programme, however, I am dubious about the data quality of that particular measure and this goes back many, many years in that it is open to a little bit of interpretation when that’s a delayed discharge.

The governance structures of the Alliance Agreement were such that the Alliance Board – with the senior leaders – was the primary reporting forum for such data. Although the boards of the individual organisations each received progress reports from the Alliance Board, ownership of the performance metrics sat with the Alliance Board. At the same time as these somewhat disappointing metrics were being reported, the Alliance Board was undertaking the complex work of establishing the ICO. This brought about considerable changes to the working lives of those affected, in particular city council staff. As we have seen, motivating such staff and making the considerable changes needed required enthusiasm and momentum to be generated, which in turn required a positive narrative of success. Thus, in engagement events, a positive message about the achievements of the SICP was required. It is possible that this inhibited more critical reflection on progress.

This suggests a further mechanism, which may be important in the operation of feedback loops. The presence of the most senior leaders from the partnership organisations on the Alliance Board was very helpful in establishing the programme. However, as implementation proceeded, it is possible that the fact that ownership of performance metrics sat at Alliance Board level acted to limit independent or critical scrutiny by the boards of the constituent organisations. Thus, our study suggests that, although a strong governance structure is important in establishing a programme such as this, which requires joint working across organisational boundaries, it is also probably important that the individual boards retain ownership of the performance of the collaboration, and that those in receipt of the information are not limited in their ability to respond by the demands of implementation.

The SICP did not establish any specific incentive mechanisms at programme level beyond the overall incentive that if savings were made they could be reinvested in relevant services. As we have seen, the Alliance Agreement made reference to the establishment of risk and benefit sharing mechanisms, but these were not formally elucidated. In the other workstreams, incentives for engagement were indirect, couched in terms of the ability to provide a better service.

Rule 3: attend to history

Our interviewees and those we observed in meetings clearly expressed the opinion that the establishment of the SICP owed much to local history, highlighting longstanding collaborative working and working relationships over a considerable period of time:

So in Salford, we’ve got a very strong record in terms of joint working. So from a commissioner-only perspective between the council and the PCT [primary care trust] that was and the CCG, we’ve got a track record of pooled budgets and the council taking lead for commissioning on services and CCG for the others. So we already had pooled budgets in place for immediate care, for the equipment service, for learning difficulties. And we’ve got joint appointments. So we’ve got a pool of commissioning managers that work across the council and the CCG as well. So we’ve got some very good examples of how we’ve worked collectively as commissioners. So we’ve got that history.

At the same time, it was acknowledged that the geographical and organisational context (shared boundaries and similar geographical coverage) was important. Moreover, this has been stable for many years:

Salford has quite a reputation for being a very strong partnership-focused district, and if you were to look at the underpinning behind that there are a number of aspects that I think it’s fair to say are drivers for it, so it’s had a stable boundary, so it hasn’t had to go through constant upheaval in terms of boundary changes like Lancashire or other districts have had with bits of it coming in and going out.

Unlike the earlier study,138 there was no clear evidence that this strong shared historico-geographical context acted to limit the ambition for significant change.

Rule 4: engage physicians

In keeping with the model of major system change,138 we found that engagement must include a much broader range of stakeholders than simply physicians. In the early phases of the SICP there had been some engagement work with community service providers, social care staff and some interested GPs to define the model. Wider engagement was carried out with staff affected by the ICO. Interviews suggested that such outreach work had been fairly successful in generating a shared sense of purpose. Thus, interviews with individuals across the stakeholder organisations, revealed a consistent view about the programme. The development of the SICP was about developing a system of work rather than a series of initiatives:

So I suppose part of this is an all-system approach to seeing that the right people get the right service at the right time. So that is the aim of just enough support, I suppose.

Individuals in the CCG and the council highlighted the need to focus on prevention:

You’ve got an acute sector that has a very, very unusual leadership style, which basically I think recognised very early on that growing the acute economy was not the future, so a sense that you could not build a sustainable model for Salford Royal on the basis of just hoovering up additional acute activity, but recognising that it needed to think about new areas of business, new models of delivery, get away from simply acute focus care and begin to think about where it could operate full pathways into the communities – only into some of those areas where you might be talking about preventative types of activities.

However, as we have indicated, engagement of the broader population of local general practices was limited, and this limited the ability of the ICO to deliver its more ambitious plans for primary care. General practices remained independent contractors and, although practices are members of the CCG, it is not clear what this ‘membership’ really means.142 The local experience suggests that CCG status as a membership organisation does not mean that CCG leaders can speak unequivocally on behalf of the members. The CCG was a key partner, but GPs were more detached:

Salford who had basically done a lot of work on the ICO but were finding that general practices’ role within the ICO was probably actually further away than it had ever been, but with the failure of their local [in inverted commas] GP federation to engage, but also the fact that actually general practice had very different priorities.

General practice engagement proved problematic in two ways. First, as discussed in implementation 2 (see Chapter 11), in the early stages of MDG development, general practice involvement was not always easy to obtain:

I can talk from personal experience about my practice, my practice is one of the practices involved in the MDGs and our experience has not been positive so far of MDG working, in that we don’t feel we’ve got anything out of it, we don’t feel it’s reduced admissions, readmissions or anything, so I expect it to be quite negative. To such an extent that the partner who’s going stopped going so our practice hasn’t been involved and we’re the only practice in [the neighbourhood] that hasn’t been involved.

General practitioners struggled to take time out of practice, and good engagement was obtained only when reimbursement was increased. Second, GP engagement in the ICO was also limited. Investigation by an independent consultant revealed significant pressures:

Then actually that was quite revealing in itself in that there was this perception that GPs were not engaging, well actually it was just the fact that they weren’t informed and it wasn’t that no one was trying to tell them, it was just once again that some of them are actually worried about their very survival beyond the end of this year, so people start talking about stuff that’s going to be happening in the next few years, it sort of becomes abstract for them.

They also expressed concerns that the foundation trust was becoming too dominant:

I know, and people keeping asking why SRFT [Salford Royal Foundation Trust] are in charge of the neighbourhoods. I’ve said that SRFT are not, this is a partnership. So in terms of primary care, we have suggested that people who join the neighbourhood groups can be represented on the ICO group.

These findings suggest that the need identified for ‘system-wide authority’ invested in individuals or groups in order to align multiple stakeholders138 may be difficult when general practices need to be engaged in a change programme.

More widely, there were also some issues with engagement with other stakeholders.

For example, some of those working in community assets found that they were isolated from the rest of the programme and experienced confusion around the terminology (often medicalised) used by others in the SICP:

To come in cold and then try and understand what it was about and then try and develop well what does . . . because in the end community assets is a bit, I don’t know, I suppose it sits outside slightly or did sit outside slightly. In the early days people really thought about what that would mean or how that might fit within the programme, people were still perhaps thinking about services, so the council services, about hospital provision, they were thinking much more along those lines. Whereas this project’s grown and developed and community assets have been able to influence a bit more, people are now starting to think about well actually the priority is what can we support to enable people to stay at home and live their lives.

Rule 5: engage with patients and the public

This issue is covered in implementation 2 (see Chapter 11) and in PPI (see Chapter 3).

Section 3: answering study questions

In this section we briefly summarise the evidence relating to our original objectives. The intention here is to bring together the evidence that we have presented in the previous sections in summary form in order to answer our initial research questions, before putting these in context with reference to other research and our analytical framework in the Discussion.

How do commissioners view the programme, what they expect from it and how it is seen in terms of their objectives?

It was envisaged that the SICP would be seen by the CCG as something they were commissioning, alongside other programmes. In practice, however, CCG leaders were committed to the programme as equal partners. The SICP was seen by the CCG as essential to contain costs and improve quality, and there was a significant commitment to partnership working, whereby the needs of individual organisations were subsumed to the needs of the programme.

However, the development of the ICO and the institution of a ‘prime provider’ contract led to the establishment of formal governance arrangements which reintroduced a separation between commissioners and providers. At the time of data collection, the implications of these changes to the governance and the formal ICO arrangements were still unknown. In particular, it will be interesting to see whether or not the reintroduction of a separation between commissioners and providers leads to a different approach to outcomes and performance management.

How is the programme viewed by strategic partners such as the local authority and how is it sustained under financial pressure?

History played a pivotal role in encouraging the main stakeholder organisations to develop the SICP and the Alliance Agreement. Positive experiences of working together in the past enabled them to develop the SICP and recognised that they all had a vested interest in the programme. All stakeholders discussed the potential difficult decisions that would need to be made. However, they believed that the organisations were willing to face organisational challenges without walking away from the programme. The collective success of SICP was deemed to be more important than individual organisational gains.

The financial pressures that were being faced by all organisations provided an incentive to senior leaders to support their organisations to work differently. Although the foundation trust and CCG were perceived to have a strong financial position, there was recognition that all organisations were working together, and, therefore, the shrinking local authority budget was not considered to inhibit partnership working. However, it remains to be seen in the longer term whether or not developing financial pressures affect the work of the ICO.

The role of Greater Manchester West Foundation Trust (GMWFT) in the SICP was different from the other three stakeholder organisations. GMWFT provided services to a wider geographical footprint, and its interaction with the programme was perceived to be more distant at times. For example, GMWFT did not have as many staff working on the SICP or attending high-level meetings. This different relationship was also identifiable in the move towards the ICO. GMWFT did not have a formal role within the organisation, and its services were to be subcontracted by the prime provider.

The local development of SICP was further supported by national policy and an appetite to introduce new models of care (vanguards), which provided Salford with an opportunity to get additional investment into the local health and social care economy. Moreover, the vanguard status also gave Salford organisations the prospect of recognition as exemplars of new approaches to service delivery. The decision to move to a formal ICO was made collectively by all stakeholder organisations. We were unable to find any evidence that this decision was based upon an appraisal of the impacts of the SICP; the focus appeared to be on the prevention of future problems rather than evidence of SICP success.

Overall, the programme involved a strong partnership between all the organisations involved. All stakeholders that we interviewed expressed their commitment. However, the question as to how the SICP figured in the broader strategic plans of the stakeholder organisations was reduced in relevance by the decision to move towards an ICO. It is possible that the early decision to move towards an ICO was prompted, in part, by financial pressures, but this was not clearly articulated by those involved.

How does the programme impact on the work of the two foundation trusts, in particular how the integrated community and acute provider adapt to reductions in inpatient activity?

This question presupposed that acute hospital activity would be reduced. In practice this has not happened (see Chapter 12).

How does the programme impacts on primary care, in particular general practice?

We have described and explained how the SICP, overall, struggled to engage with general practices, and we have considered some of the underlying causes of this, as well as identified solutions.

How far are the financial incentives (explicit and implicit) in the local health and social care system aligned with the ambitions of the programme?

The SICP did not put in place any specific incentive schemes, other than direct payments to GPs to take part in MDG work and the implicit incentive that any money saved could be reinvested in services. The initial funding for GPs was not deemed to be adequate to cover their costs and time; therefore, additional funding was required by the CCG to ensure GP commitment. The CCG funded local GPs through a local enhanced service for patients with long-term conditions. It was found in implementation 2 (see Chapter 11) that GPs were being funded twice – both by the local enhanced service and through the SICP – for doing similar work. This demonstrates how the objectives of the CCG mirrored that of the SICP, but also highlights difficulties associated with engaging GPs. Over and above the GP-related work, we did not see any evidence of reliance on specific financial incentives to implement SICP, other than the general incentive that it was argued that the programme would improve the sustainability of the local health economy.

Discussion

This chapter has explored the initial establishment and the early operation of the SICP, the introduction of the ICO and a move towards an ICS. The governance arrangements in Salford have been changing rapidly. This makes it difficult to identify specific commissioning mechanisms that could potentially underpin ‘success’. Indeed, we found a disconnect between commissioning and governance activity and the implementation of programmes of work on the ground. This is an important finding. In addition, we have highlighted the factors supporting the development of the programme and explored the nature of the commissioning and contracting involved. In this final section we will consider the wider lessons arising from the commissioning and implementation of the programme to date.

What type of integration does the SICP represent?

As discussed in the initial literature review (see Chapter 1), there are many different ways of defining integrated care. Bringing together our observational evidence, interviews and documentary analysis, we have identified two somewhat different ‘programme theories’. Figure 6 sets out our interpretation of the theory underlying the SICP as it was conceived. Figure 7 sets out our interpretation of the programme theory underpinning the latest developments.

FIGURE 6 Overall programme theory underlying SICP (initial thinking). LA, local authority; SRFT, Salford Royal Foundation Trust. (Figure not reproduced here; see the original article.)

FIGURE 7 Overall programme theory underlying Salford ICO/ICS (from July 2016). (Figure not reproduced here; see the original article.)

In its initial phases, the SICP was underpinned by a strong ideal of partnership working. The three programmes of work were identified as targets for service change and it was assumed that the experience of working together would break down organisational barriers and support wider improvement. At the same time, the programmes of work would support local people in becoming more resilient. This suggests a model of integration in which the focus is on functional and service-level integration, in which staff from different organisations work together across organisational boundaries. From this perspective, the integration of systems [such as information technology (IT) or financial systems] develops out of what is required to make collaborative working possible.

For the ICO (and subsequently the ICS), those involved told us that closer structural integration (with organisations either subsumed into the foundation trust or subcontracted by them) would lead to the embedding of functional integration, in which working together across organisational and professional boundaries would become the norm, leading to better outcomes and patient experience. This view of integration assumes that the integration of systems, financial flows and management systems is a prerequisite for integrated working. In this model, integrated organisations and systems come first, with integrated working flowing from this. The initial vision underpinning the SICP focused on the value that would be derived from the functional integration associated with the three programmes of work. By contrast, the vision underpinning the ICO suggests that, to be successful, such functional integration requires structural integration.

Our study, which has finished just as the development of the ICO is coming to fruition, cannot adjudicate between these two approaches. Indeed, it could be argued that these changing underlying assumptions and beliefs simply reflect the changing context of the NHS. This includes two important macro-level pressures: the national drive towards the formation of new models of care under the vanguard programme, in which elements of structural integration, although not essential, are encouraged; and a worsening financial environment in which all NHS and social care commissioners and providers are struggling to balance budgets. In this environment, the creation of larger, more streamlined organisations which are able to reduce duplication may seem an attractive proposition, regardless of the impact on the delivery of more integrated care.

Supporting and commissioning large-scale service change: comparison with other research

We have used the published framework for understanding large-scale system changes.44,143 This proved valuable in analysing our findings, and our evidence confirms and amplifies the importance of some elements embodied in the framework.

First, the local experience highlighted the value of the clear scheme of delegation, which allowed middle-level managers to exercise local leadership within delegated resources. This allowed the programme to be implemented while senior leaders were engaged in developing the next phase.

Second, our study reaffirmed the importance of history and geography in providing a context within which change programmes can be implemented. This included good personal relationships, which had developed over many years, and a local geography, which allowed coherence around a core group sharing the same geographical footprint. Although some senior personnel did change towards the end of our fieldwork period, respondents were clear that the trust developed by working together on complex agreements over time was a vital ingredient in its ability to implement the ICO.

Third, our study suggested an interesting nuance in the need to establish feedback loops, particularly in the context of an evolving programme. The establishment of an Alliance Board, which included the most senior leaders from the contributing organisations, may have acted to limit the scrutiny of outcomes. Our study suggests that, although the establishment of a strong governance structure for a collaborative venture is important, it is probably also important that the individual boards of the collaborating organisations retain ownership and scrutiny. In establishing feedback loops, it is thus important that those in receipt of the information are not limited in their ability to respond by the demands of implementation.

Finally, our study re-emphasised the need to engage with stakeholders. Although some emphasise the need to engage with a wide range of local stakeholders,143 the local experience suggested that engagement of GPs had a specific impact. The plans involving general practice included in the ICO vanguard application remain some way from fruition and have required an intensive process of engagement.

Looking at previous research, the most comprehensive analysis is that of the ICPs undertaken by RAND.51 In Table 26, we compare the findings. The RAND report also highlighted potential ‘enablers’ to integrated care, which are compared in Table 27.

Taken together, it can be seen that the SICP fulfils many of the conditions highlighted by the RAND report as underpinning the successful programmes, and this could be said to be reflected in the success in establishing the three programmes of work making up the SICP (albeit more slowly than intended).

Emerging metrics that suggested that targets were not being met were not acted on, and we have already highlighted the failure to fully engage with GPs. Furthermore, as we have highlighted, the goals of the programme continued to develop while it was being implemented, making it difficult to assess fully the impact of these issues. RAND highlighted the impact of increasing scale and complexity, and it remains to be seen how the wider changes enacted under the ICO play out.

Evidence relating to the potential transferability of the SICP

This evaluation is intended to generate learning that could be applied to other areas, and we have tried to do this by using and building on existing frameworks for understanding major system change. However, local contexts and relationship dynamics are perceived by those involved as the key ingredients enabling the development and implementation of the programme:

The programme itself didn’t come from thin air. The programme came from personal relationships built up over a programme of time across organisations, and so there was an awful lot of good [learning disabilities service] . . . So they had something they could see and was tangible within Salford, that they thought, ‘yeah, well if it can work there, it can work on a lot bigger scale, because we’ve seen the benefits for the individuals concerned who receive the service’.

Thus, the approach taken in the SICP will not necessarily suit all populations. A key early stage in the local journey was to explore the widely praised ‘Torbay model’ of integrated care.144 Local leaders told us that, although successful in Torbay, on closer review the local population needs were different and therefore tailored solutions were required:

I think that Torbay/Sally Ford storyline is one that illustrates the limitations of thinking that you can do lift and drop. Populations are different. There are aspects of these things which you can mirror, and I’m sure when you talk to the people who are in the detail they will talk about the way in which they’ve looked at some of the work that Torbay did . . . There’s a sense for me about constantly reminding people about the population demographics.

So in Torbay, they are gentrified, relatively affluent, moved to the area, usually short on family connections or they were distant, and quite often are healthy till later in life because of their financial status as much as anything; whereas Sally Ford has quite often lived on the streets she was born in, has a big family network, is considerably impoverished, by comparison to Mrs Smith, and ends up with a long-term condition probably 10 years earlier than her, so the whole pressure in the system is different but also the ways of managing it are very different, because she has a community network of support that we can tap into and use. In Torbay, they didn’t.

Concluding remarks

In our early chapters, we highlighted the complexity of integrated care. The goal of integrated care is generally to improve patients’ experience of care, with less duplication and fewer ‘hand-offs’ between different organisations. There is an underlying assumption that this will, in turn, lead to better outcomes at reduced costs. Although the initial work done by the SICP included the development of a clear model of the needs of the population, the programme of work in Salford focused on interventions that were relatively modest in their scope and reach. However, as we have demonstrated, even these relatively modest interventions required a complicated, multilevel and continually evolving structure to oversee, commission and manage. Furthermore, even before the programme was fully established, it was decided that working together in partnership would not be enough and that structural integration was required.

Evaluating such a programme is extremely difficult, as it requires the evaluators to try to unpick and differentiate between the impact of interventions, whether or not interventions were implemented as planned and the factors affecting that implementation. Failure to meet objectives might reflect an inappropriate intervention, a failed implementation or a changed context. It was hoped that the design of this evaluation, exploring implementation at the system/commissioning as well as the operational level, might help to unpick this complexity. However, although we have been able to highlight some issues that have been important in supporting this change programme and which are relevant to wider issues of system change, the continually changing oversight and commissioning of the programme makes it very difficult indeed to know which aspects of this helped, which hindered and what would be necessary for anyone trying to replicate the programme.