How improvement approaches can support neighbourhood health models

There is no shortage of speculation about what the 10 Year Health Plan will and will not include. One thing is certain though: a large part of the plan will centre on the government’s vision for neighbourhood health. Seen by the Health Secretary as pivotal to the delivery of his three shifts, the neighbourhood health model aims to drive ​‘an integrated response from all parts of the health and care system’ to the challenge of ​‘delivering more care at home or closer to home’. The government has laid the foundations for this work by publishing a set of guidelines ahead of the 10-year plan. 

But while the government’s direction is clear, there is still work to be done to show what the neighbourhood health model ​‘will look or feel like for citizens and staff’. Behind the scenes it is reported that there is not only ​‘fervent disagreement’ about defining core principles and components of the model, but a risk of mission creep as an array of policymakers try to ensure that their policy priorities are reflected in the neighbourhood health vision. Political wrangling over the purpose and content of major national programmes is not uncommon though. It is one reason why the Health Foundation is working with THIS Institute and Ipsos to develop practical, evidence-based guidance for those charged with developing such programmes. 

As neighbourhood health leads develop and implement their programmes, they should take the time to consider how improvement principles and approaches can help them – a point underlined in NHSE’s guidelines. Neighbourhood health systems, they state, should look to build on the NHS Impact improvement framework and embrace continuous improvement. It is a view echoed in the Fuller stocktake on integrated primary care, which has heavily influenced the government’s thinking on neighbourhood health: 

There are three key activities connected to the design and delivery of neighbourhood health models that would benefit from improvement approaches and the expertise of improvement practitioners. 

The first is the co-design of a collective vision and plan for neighbourhood health between health and care staff from all sectors, patients, service users and the wider community. Participatory design has been at the heart of improvement practice for many years. Improvement teams are skilled not just in involving a broad range of stakeholders in identifying, planning and delivering change, but ensuring that the eventual intervention is owned by each of them and reflects what matters most to them – both of which are crucial if the change made is to be embedded and sustained. They recognise that good co-design needs careful facilitation and mature collaboration skills: it’s not enough to get the right people together and organise a medium in which they can work. Awareness of the power or knowledge imbalances and tensions between participants, and finding ways to mitigate them, is vital in order to arrive at a lasting common vision. Done well, co-designed visions and plans provide the foundation for impactful change, especially if the collaborative principles and practices underpinning them continue to be applied at each stage of the design and implementation of the change interventions identified in the plans. 

What’s more, improvement teams, working alongside designers, are used to operating at different scales. They have the necessary tools to support co-design work at team or service level, across clinical pathways spanning organisations, and at organisation or local system level with all the complexity and political sensitivities that entails. This flexibility, coupled with the capacity to connect and align the collective priorities of frontline teams and service users with those of the wider system, is a key skill, and one vital to the success of multi-level, boundary-spanning neighbourhood health models. 

The second activity is the planning and implementation of change, to which improvement approaches would bring rigour and consistency. Effective improvement interventions are based on a deep understanding of care processes and systems and the factors that strengthen and impede their operation. This allows the root causes of operational challenges to be identified and tackled. It avoids knee-jerk responses based on inadequate information or politically convenient, but flawed, assumptions about their cause. Another strength of improvement approaches is that they provide a consistent, standardised and repeatable process for designing, testing and refining potential solutions, but are flexible enough to be used in a variety of contexts. 

At its best, improvement combines a commitment to disciplined, evidence-based practice with a pragmatism that allows the development of timely, real-world solutions. In the complex operational climate in which neighbourhood health models will be developed, with multiple change ideas of varying quality and utility vying for attention, the rigorous yet pragmatic approach taken by improvement teams has much to recommend it. As such, a priority for those leading local neighbourhood health models should be to identify and coordinate the improvement capability held by local partners and to work with organisation and system leaders to plug any critical gaps that exist. 

The third activity is the development of local learning systems that allow knowledge, data and innovation to flow unimpeded across organisational and service boundaries and enable those leading change to gain support, confidence and a sense of community. Such systems serve multiple purposes. In the context of the development of neighbourhood health teams they can surface learning to inform the overarching strategy and the practical steps required to establish functioning teams and viable work programmes. They can also generate rapid advice and support to help people deal with design and implementation challenges, such as how to plan and implement a new service model at the same time as managing an existing service (so-called ​‘double running’). 

A further benefit of learning systems is that they facilitate and cement multiple layers of connections that people can draw on when expedient. Most of the time people will want to draw on connections within their own neighbourhood team, but there will be times when it is useful to call on the knowledge and expertise of other teams in their Integrated Care System (ICS): a learning system provides the space for both kinds of connection to emerge and become embedded. 

The value of learning systems is underlined by the fact that a host of efforts over the years to drive integration across organisation and professional boundaries have been undone by a failure to set up effective information sharing. And despite being identified as a challenge in countless analyses and evaluations of integrated care models, it is a problem that ​‘continues to crop up’. One reason for this may be that while the problem is well understood, the skill, time and resource required to set up an effective learning system are consistently under-estimated. Work to set up structures and governance arrangements tends to be prioritised, leaving little time for the design and delivery of peer networks or data sharing. 

Providing learning systems are prioritised by local leaders, there is every reason though to believe that neighbourhood health teams can avoid the problems encountered by previous integration efforts in setting up knowledge and data sharing arrangements. After all there is a growing number of well-established learning systems and networks that they can turn to for inspiration and support. A case in point is the Q community, whose members have been sharing improvement insights, skills and ideas across the UK and Ireland for the last decade. Q is ideally placed to provide strategic advice and practical support to neighbourhood health teams. 

Getting neighbourhood health models up and running will be no easy task, especially given the intense scrutiny those delivering them will be under, and the inevitable pressure they will face to deliver early results. Using improvement approaches will not lessen these pressures. Nor will improvement approaches deliver instant solutions to the perennial challenges involved in trying to integrate services with very different priorities and cultures. But they can help to foster a way of thinking and working that can help people make sense of complex delivery challenges, and find ways to tackle them that are impactful, long-lasting and have broad appeal and support. For this reason, it is important to ensure that improvement is at the centre of efforts to develop neighbourhood health models.