System-wide governance and leadership

 

How have leaders collaborated across local systems to ensure well-planned service delivery for older people during the pandemic? We looked at governance structures and how effective these were in supporting safe delivery of care – and what providers have learned, and how they have shared learning.

We wanted to find out how local leadership and governance across a system and a shared plan had helped services to care for people. Our work in local systems in recent years has showed that people who use services can benefit where there is a common vision and purpose that is shared between leaders in a system.

Across the 11 local areas we reviewed, we found different kinds of plans were in place to manage health and social care services in the event of an emergency. We were told that pre-existing emergency plans were intended to deal with the likes of a flu pandemic or a single incident – not a crisis on the scale of COVID-19 – and they therefore needed to be adapted. We heard how some areas were not prepared for many types of service being shut down at the same time.

Where we found well planned governance, clear decision-making arrangements and escalation plans, those system-wide responses were most effective

Local leaders in some areas told us that COVID-19 has brought about an increased focus on shared planning and system-wide governance that includes all parts of the local system. A number of things went well in some places, including:

• Governance structures with clear process for decision-making and escalation of issues across the system that enabled an effective system-wide response.
• Increased communication and collaboration, particularly through the use of cells focusing on specific pathways of care. This enabled information sharing, good practice, collective decisions and escalation of issues.
• New or improved lines of communication and collaboration between sectors to share information and provide more joined-up care.

Some organisations found that responding to COVID-19 brought them towards what was described as a shared purpose, and enabled them to strengthen relationships with system partners. The ICS in Sussex was newly formed in April 2020 and, while leaders from Sussex CCG and Sussex Partnership Trust acknowledged that the relationship had been formed before the pandemic, they felt it had galvanised change overnight towards real collaboration.

Across the localities we reviewed, there was often an acknowledgement that COVID-19 had accelerated collaborative working across health and social care, but there needed to be a focus on communication and engagement for the local systems. It was widely recognised across the areas we visited that local communication was the key to local success.

Where we found multiple or unclear governance arrangements, those areas experienced higher levels of confusion and duplication of effort. The views of sector partners varied as to the effectiveness of joint and supportive working arrangements, particularly between care homes and GP practices

In some places, there were barriers to good shared planning and governance. Multiple governance structures could lead to confusion and duplication of effort. There was a perception in some cases that communication across the system was disjointed, and reportedly a lack of clarity in terms of who was in charge. Sometimes there was a disconnect between the views of ICS leads and providers on the ground.

Some services were left out of system-level discussions and acute care dominated. There was sometimes a lack of communication between sectors – mainly hospitals and social care when discharging patients.

Some care homes said that it was difficult to get GP access and others said that virtual ward rounds were helpful. Some care homes didn’t know what the offer was to them. In some cases, GPs were reportedly not visiting care homes – some adult social care services said they felt like a second-class service. In one system, this was described as a rift between some adult social care services and GP practices. This was because of access issues within care homes to primary care services and the additional responsibilities being placed on some adult social care staff to provide verification of deaths.

In some care home interviews, it became apparent that some services felt completely isolated and stranded. An example was given of a care home manager that had been called at 10:30pm one night to inform them that 24 of their residents had tested positive for COVID-19. They were then left overnight to deal with the situation unsupported.

In such a fast-moving environment, leaders found it was challenging to make decisions to give the clarity that providers wanted. Local systems told us that national guidance was not always published with the speed needed to support them, causing confusion for staff when local decisions had to be changed to meet national requirements. We also heard how centralised guidance was not flexible enough to be readily applied to different local areas with very different local circumstances and populations. Providers felt overwhelmed by the amount of information changes and guidance.

We heard how clearly defined roles and hierarchical structures were important for escalating and responding quickly to emerging issues. Where there were multiple governance structures running alongside each other or recent changes in leadership, there was sometimes confusion around roles and responsibilities. For example, in one ICS the cells ran separately to the local resilience forum. Although each structure communicated with the other, there was a challenge to blend the two together that was said to have led to duplication of effort. The pace of change also meant that a lot of people felt unclear about what they should be doing.

Not all of the local systems we reviewed experienced good governance across the system. In some there was little discussion of system-wide governance and collaboration. There was sometimes a disconnect between the views of system leaders and providers at ground level, with providers, particularly from social care, unaware of any collaboration at ICS level.

Areas with sector and pathway oversight cells secured increased communication, timely information sharing and collective partnership decisions

New governance or command and control structures were created in response to the pandemic. The importance of these has been highlighted to us by ICS and STP leads, commissioners and some trusts.

Collaboration between care provider leaders happened through the creation of cells or groups, linked to the local resilience forum (LRF) or similar governance structures, to plan and deliver services across the system for specific pathways of care or population groups. These cells or groups brought together different care providers and sectors and enabled them to share information and good practice, escalate issues and make collective decisions quickly in response to emerging issues or events. Information and decisions could then be cascaded to the relevant organisations.

Sectors did not feel consistently engaged in the coordination of responses to the crisis

We found significant variation between localities when it came to social care inclusion in the collaboration for planning and delivery of services. We heard about an improved relationship between health and social care in some local systems, but in others there was little mention of interaction between them. People we spoke to felt that health partners, or specifically acute trusts, dominated the decision-making. Sometimes there were mixed views – where, for example, social care was not fully included in the system.

There was a recognition in many systems that adult social care needed to be more effectively integrated into the system. We heard in some areas that adult social care providers didn’t always understand the shared strategic approach and didn’t always feel that services met the needs of the whole populations. We also heard from many adult social care providers that described feeling overwhelmed and isolated.

Some dentists also told us that they felt excluded from system-level collaboration and reported a lack of communication.

Ambulance services spoke about the challenges of covering a large geography that means they cover multiple systems without necessarily having the resource to effectively engage with them all. They also tend to be led by national rather than local directives, and during the pandemic were under the strategic command of the National Ambulance Coordinating Centre.

Pre-existing structures and relationships enabled more effective collaboration

Providers consistently highlighted that the structures they already had in place, and the strength of existing relationships between system partners, provided the building blocks for collaboration in responding to COVID-19.

Some providers talked about the value of existing relationships with other providers and stakeholders, including formal networks. For example, participants linked the strength of system working in Frimley to the fact that it was already a mature ICS system – strong and trusting personal relationships between system partners already existed.

There were also examples of informal action. Early in the pandemic, the registered manager of an ‘extra care’ housing provider in Gloucestershire used a network of contacts from a training session she had attended to get advice from public health professionals when she had COVID-19 positive tests among residents and staff.

Forums and other groups were valued for sharing information, good practice and ideas – and sometimes resources such as PPE or beds. For example, Brent Care Homes Forum held weekly meetings that enabled open conversation and good peer and professional support. Bedfordshire, Luton and Milton Keynes ICS dentists quickly established a collaborative approach, setting up urgent dental care cluster meetings and enabling them to share PPE, good practice and risk assessments.

Providers have also discussed the value in increased support and communication from commissioners and other bodies. For example, in Devon STP, social care providers highlighted the helpfulness of regular contact from local authority teams, such as a quality assurance and improvement team, and a new care home liaison team.

We also heard about positive outcomes from good leadership in local medicines optimisation leadership cells. They brought leaders together, and regional medicines optimisation webinars helped local leaders to understand both national and regional challenges with medicines, and to share learning.

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How did care providers collaborate to keep people safe?