Chris Ham, Chief Executive at The King’s Fund, highlights the 16 lessons needed to make a reality of integrated care, drawing on work by the Fund and others to provide examples of good practice.

1. Making integrated care
happen at scale and pace
Lessons from experience
Professor Chris Ham
Chief Executive, The King’s Fund

2. 1: Find common cause with partners and be
prepared to share sovereignty
› Find common cause in overcoming fragmentation between
services and developing more integrated care
› Example of the ‘Knowsley pound’ in north-west England, where
leaders of different public services came together to agree how to
deliver improved value for the local population from the available
public funding
› Organisations may have to share sovereignty in pursuit of greater
good for population – this is not always easy

3. 2: Develop a shared narrative to explain why
integrated care matters
› Develop a shared narrative or story to explain to staff and users
why integrated care matters
› Example of Mrs Smith, a fictional ageing local resident, used by
Torbay Council and NHS partners to identify and express the
desired outcomes from integrated care and to guide local service
change

4. 3: Develop a persuasive vision to describe
what integrated care will achieve
› Describe an alternative and better future to motivate and inspire
providers to work differently
› This includes developing an understanding of what integrated care
means and how it will help to overcome challenges

5. 4: Establish shared leadership
› Bring together leaders from the NHS, local authorities and, where
appropriate, other public bodies and the third sector
› Sound governance is crucial, including clarity about decision-
making and accountability
› Health and wellbeing boards may act as the focus for collective
action or may replace existing system leadership arrangements
› Senior executive support and dedicated programme management
are key to implementation and execution

6. 5: Create time and space to develop
understanding and new ways of working
› Work with others to deliver improvements through use of
influence, persuasion and ‘soft’ skills
› Develop trusting relationships with leaders in other organisations
through creating time and space to understand each other’s
priorities and styles
› Clinical leadership is crucial
› Establish shared leadership at all levels, not just at the top

7. 6: Identify services and user groups where
the potential benefits from integrated care are
greatest
› Decide where to focus – it is difficult to tackle the needs of all groups
at the same time
› Greatest opportunities often found among people with multi-
morbidities
› Needs of older people are often given high priority as intensive users
of health and social care, and accounting for high proportion of costs
› Example of holistic assessment system for older people in South
Warwickshire across health, social care and the third sector, to
identify older person’s needs and priorities

8. 7: Build integrated care from the bottom up as
well as the top down
› Main benefits of integrated care occur when barriers between
services and clinicians are broken down, not when organisations are
merged
› Create integrated or multidisciplinary teams comprising all
professionals and clinicians involved with the service or user group
› Develop single point of access, single assessment process, and
ensure close alignment of team with other providers including GPs
› While co-location and a unified management structure are
important, most crucial is the alignment of goals, collaboration and
joint working
› Use registries and other data sources to get to know the population
and to stratify needs – including people currently in need and people
who may become vulnerable in future

9. 8: Pool resources to enable commissioners
and integrated teams to use resources flexibly
› Identify overall expenditure for defined populations and user groups
and use budgets flexibly to cost-effectively allocate resources
› This may result in funds that are nominally allocated to one service
(eg, the NHS) being used to increase investment in another service
(eg, social care)
› Start by understanding how different organisations currently use
funding through resource mapping
› Example of Essex – work on integrated health and social care
commissioning for older people and the Whole Essex Community Budgets
Programme

10. 9: Innovate in the use of
commissioning, contracting and payment
mechanisms and use of the independent
sector
› Innovations in contracting include use of lead providers, alliance
contracting and capitated and outcome-based incentive contracts
› New payment mechanisms include year-of-care tariff and
capitated budgets
› Be open to role of third and independent sector providers in
providing integrated care alongside public sector providers
› Critical requirement for success is willingness of different
commissioners to work together
› Example of Cambridgeshire, where exploring outcomes-based
contract for frail older people

11. 10: Recognise that there is no ‘best way’ of
integrating care
› No evidence that any one form of integration is superior to others
› Main benefits of integrated care derive from clinical and service
integration, not from organisational integration
› Small-scale pilots focused on the needs of people with single
diseases and conditions are unlikely to deliver benefits on the
scale needed

12. 11: Support and empower users to take more
control over their health and wellbeing
› Use of direct payments and personal health budgets has benefited
some service users
› Scope to support and empower users through approaches such
as: care planning; the use of care managers; care navigators and
advocates to support people with complex needs; support for self-
care; and the use of telecare and telehealth.
› A range of interventions used together likely to make a bigger
impact than a single intervention
› Example of NHS North Yorkshire and York large-scale telehealth
project for people with long-term conditions
(www.nyytelehealth.co.uk)

13. 12: Share information about users with the
support of appropriate information
governance
› Find local solutions to information-sharing
› Example of South Warwickshire and their electronic shared-
assessment system
› Ensure information-sharing is supported by appropriate
information governance
› Example of north-west London where board-level commitment to
information governance and seeking consent of patients to the sharing
of their data in care planning

14. 13: Use the workforce effectively and be open
to innovations in skill-mix and staff
substitution
› High–quality integrated care dependent on team-working
› Vary skill-mix and use staff substitution in teams,
eg, nurses and pharmacists taking on roles previously performed
by doctors
› Establish new roles,
eg, health and social care co-ordinators in Torbay
eg, development of hybrid roles spanning social care and
community nursing

15. 14: Set specific objectives and measure and
evaluate progress towards these objectives
› Objectives need to encompass user experience, service
utilisation, staff experience and the costs of delivering care
› Measure progress towards these goals frequently
› Understand the relationships between inputs, process and
outcomes
› Example of Veterans Health Administration (VA) in United States
www.kingsfund.org.uk/audio-video/kenneth-kizer-achieving-
integrated-care-highlights

16. 15: Be realistic about the costs of integrated
care
› Need to invest in new models of care before resources can be
released from existing models
› Example of modelling savings from integrated care pilot in north-west
London
› Little if any evidence that integrated care can be delivered more
cheaply but there is evidence that it can enhance the quality of
services
› Example of VA in United States

17. 16: Act on all these lessons together as part of
a coherent strategy
› Plan over an appropriate timescale (at least five years and often
longer)
› Change is rarely linear and the effect of different actions is hard
to predict