Report: Moving from the margins: The challenges of building integrated local services

Published by: Collaborate and Turning Point
Authors: Hannah Anderson, Anna Randle, Sarah Billiard and Henry Kippin
Published: September 2016

This paper is based on a roundtable discussion and consideration of three integrated service models: Connected Care, The MEAM approach and West London Zone. The aim of the exercise was to explore the question “why, despite the relative maturity of multiple models and evidence of their effectiveness, do integrated systems remain at the fringes of local public services?”

I approached the report with a slight feeling of trepidation. How many reports like this are out there, extolling the virtues – real or proposed – of integration, citizen led, place-based systems? Maybe it’s report fatigue from seeing a variety of ‘ingredients’, ‘components’ or ‘checklists’ for integration and collaboration. One with seven insights did not encourage me as a concept.

But I admire both organisations and am always interested to read about Henry and Anna’s work so I went ahead. And I am very glad I did. The first plus point is that it is short, just 16 pages, and nicely structured. Second, an early statement made me smile as it is wonderfully controversial:

“Contributors to the discussion were highly cognisant of the financial and demand challenges facing local public services. Yet the challenges were felt to be products of the behavioural, the cultural and the systematic, rather than the purely financial pressures within the system.”

This is not what those who are clamouring for additional funding would wish to hear.

Then there are two stand out points for me. The first is a revelation and the second is about something I increasingly talk about in my work and want to shout from the rooftops.

The revelation comes in Insight One – It’s about the principles and context (page 7) and Insight Four – Evolution and revolution: It isn’t a zero sum game (page 10). The observation is made that wider system change or lasting change in commissioning practice rarely follows small scale innovation. The authors challenge the common approach to start small, test something out, pilot it. This immediately positions the initiative as outside of business as usual. They contest that being discrete and not seen as a strategic imperative will mean that a shift in culture will not take place and scaling to become systematic not occur.

I have a couple of examples of pilots for commissioning differently which were successful and the approach is now being adopted more widely, but these are isolated cases. I believe the analysis is correct and will now challenge myself when I am advising people about where and how to get started. If I find myself saying that you can ‘derisk’ by starting small I will follow up by saying that you will also reduce or delay the chance to make a significant impact.

Insight Seven – Change requires doing less, better, not doing more (page 13) was the one that caught my attention most. The quotation used absolutely nails it for me. Although it is about Councils, the same could be said for professionals and managers.

“Power and control combined with bureaucracy are the main enforcers of the status quo.”

The flip side of power and control is accountability of course and you can understand how those who are heavily scrutinised, criticised and sanctioned will inevitable seek more assurances and control.

Like an over-controlling parent who is stifling their offspring and preventing them from learning how to get on with life for themselves, it can be hard to let go. It feels like the opposite of caring. But once this happens and the sky does not fall on one’s head (although you find the ‘non-let-goers’ often have treasured anecdotes of sky fallings) then people find that letting go can actually bring the benefits that tight control was seeking but failing to deliver.

In my work I introduce early the need to let go, to give something up. We say that collaboration means loss – of individual determination and decision making. Better to get the fears and concerns out on the table than pretend that there are no downsides.

So a helpful read even if you have to go to the end the get the killer insight.

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