Blog | Unlocking integrated care

With the release of the 10 Year Plan, we've gained some much-needed clarity on the future of integrated care with major statements outlining both the strategic intent and the mechanisms through which local NHS organisations are expected to deliver and putting neighbourhoods and neighbourhood working squarely at the centre.

Building on the foundations laid in the NHS Operational Planning Guidance, the 10 Year Plan set out the 'what,' providing a clear set of priorities for the year ahead to lay the foundations for sustained improvements in access, outcomes and efficiency, while tackling long-standing health inequalities.

As providers across the System – whether they might ultimately become ICB Clusters, Integrated Health Organisations (IHOs) or Neighbourhood Health Hubs (NHHs), what our partners are now asking us about is the ‘how’. Looking back again at an earlier foundational policy document – the Neighbourhood Health Guidelines – there’s a nascent blueprint, outlining the practical steps to implement these priorities effectively, centred around the principles of integrated working that will ultimately be embedded in the NHHs but will remain true at all levels of a System.

Using data and technology to drive more proactive, targeted approaches to care
Shifting resources from hospital to community care to treat more people closer to home
Prioritising prevention to reduce inequalities and prevent unnecessary admissions.

Capturing the lessons of PHM delivery

It is especially encouraging to see how population health management (PHM) is now explicitly presented as an important part of the solution for integrated neighbourhood working in particular.

By combining data-driven insight with whole-person models of care, PHM enables systems to shift from reactive service delivery to proactive, integrated models that keep people healthier for longer and allow neighbourhood-wide resources to be allocated based on those insights.

From our experience working with Systems across the country, we’ve seen that when PHM is applied as a practical methodology, it can unlock the type of transformation the NHS is now calling for.

So, I thought it would be helpful to share some reflections on what we've already learned from our work supporting the NHS in implementing PHM-led models of care – including the key learning resources and case studies we've developed to capture these lessons that already align with some of the neighborhood use cases in the 10 Year Plan.

Building capability and confidence in data as a tool for transformation

One of the most consistent messages we’ve heard from system leaders is that PHM is only as powerful as the trust people have in the data available to them and their ability to extract meaningful insights from it. Building the confidence and competence of local teams to use data-driven techniques is therefore crucial.

However, this doesn’t happen by chance – it requires a meaningful and deliberate commitment to transforming infrastructure, capability, and culture within organisations to embed these data-driven PHM methodologies.

The progress made across Lincolnshire over the last few years is a great example. What they've achieved is remarkable – moving from limited infrastructure to becoming one of the first Systems to fully embed PHM as the strategic operating model for their system.

Their leadership particularly emphasises the empowering role data plays in facilitating new ideas and bringing people together across organisational boundaries – it’s what their Chief Financial Officer Matt Gaunt has described as ‘the enabling impact of [our] intelligence and data on frontline clinicians’.

This is now driving forward a host of innovative projects, all grounded in whole-person care and targeting critical areas of need – an exemplary approach that goes to the heart of what integrated working is all about.

Making integrated neighbourhood teams a default delivery model within ICSs

The ambition to shift more care from hospitals into communities is firmly established in the NHS's strategic priorities around neighbourhood working and the vision of the NHHs.

Through our work with Systems, we've seen how PHM techniques can act as the glue holding neighbourhood working together, creating a shared evidence base that allows different professional groups to identify at-risk populations, design multi-disciplinary interventions, and track outcomes.

Last year, we published our PHM as an Engine for Integrated Neighbourhood Working white paper, summarising key outputs from our expert panel discussions at NHS Confed Expo. I’m proud of the work Optum has done with these systems, helping them consider shifts in resources and how data can unite professionals around value-based care.

Looking ahead, the key challenges will be:

To ensure that money flows across communities in a way that delivers meaningful improvements in care and support for patients
To apply best practice evaluation and evidence-gathering techniques to demonstrate why transformation matters and to validate different-in-kind investments
To invest in building broader and deeper relationships across professional groups to cultivate the trust and understanding that’s necessary for INTs and NHHs to succeed.

Moving from sickness to prevention – scaling community-based interventions

Perhaps the boldest ambition is the shift from sickness to prevention – a transition that will only be possible if systems can harness community-based assets to support population health.

Our work in Cheshire and Merseyside (fuel poverty) and Suffolk and North East Essex (falls prevention) demonstrates what’s possible when systems move beyond traditional healthcare boundaries. The next challenge will be scaling these community-based models, ensuring they’re central to PHM strategies and properly integrated with NHS services.

Clinicians will remain central to this conversation but, given the pressures on primary care and other services, there’s an opportunity to share the load through integrated working – exactly the point outlined in the ‘golden thread narrative’ of the 10 Year Plan around neighbourhoods as the engine of meaningful outcomes for citizens and communities. Without the right data, though, it is difficult to make informed decisions about where to target limited resources. Yes, the NHHs are said to be launching in areas identified as the most deprived but imagine the ability to layer in further data – creating a true linked data set that lets us look at health, the wider determinants, employment and education scenarios etc – to really understand where that integrated working and the NHH sites could best be placed to maximise impact on outcomes for citizens.

Conclusion

Reflecting on these experiences, what stands out is the courage of the systems we’ve worked with. Change is difficult and requires not just vision, but the willingness to take risks and invest time in something that may not deliver immediate results.

Disclaimer
This article was prepared by Rebecca Richmond in a personal capacity. The views, thoughts and opinions expressed by the author of this piece belong to the author and do not purport to represent the views, thoughts and opinions of Optum.