The human chemistry of trust, relationships and shared understandings

Delivering joined-up, coordinated care has long been an aspiration of the NHS in each country of the UK. In England, the NHS Long Term Plan announced the expansion of Integrated Care Systems (ICSs) across the country, supported by a range of structural and payment reforms, to help achieve the ‘triple integration’ of primary and specialist care, physical and mental health services, and health and social care.

However, while structural reforms can support the integration of services, they won’t by themselves be sufficient. Reshaping the way care is delivered in practice will require staff from different organisations and sectors to come together, develop new approaches and agree to work together in different ways – something we know from the Health Foundation’s grant programmes can be a significant challenge. 

Our recent Annual Event Faster progress to improve health and care: what are the ingredients? provided the perfect opportunity to explore what it takes to work successfully across organisational and sectoral boundaries, bringing together Health Foundation grant holders to share their experiences. And while some of the issues encountered were specific to particular care boundaries – like health and social care, or primary and secondary care – what was striking was just how many of the key ingredients for success were common across them all.

Of the three projects we heard from – MISSION COPD, a new model of COPD clinic offering integrated assessment and care, Pills, an innovative approach to medication reviews in care homes, and the Imperial Mental Health Crisis Big Room, which uses the Flow Coaching Academy methodology to improve care for patients experiencing mental health crisis – all emphasised the importance of a shared purpose and shared approach. THIS Institute Director Mary Dixon-Woods highlighted a poignant example from a Health Foundation project she had evaluated, one that tried to improve discharge from a hospital to care homes, but which struggled because the hospital and care homes disagreed about the underlying cause of the problem. So creating a shared understanding from the outset is key to ensure everyone is working towards the same goal – and Mary cautioned against trying to jump straight to a stage of designing solutions without first going through this vital stage of checking everyone has the same analysis of the problem. 

Another consistent theme across the projects was the importance of building relationships. Any scenario requiring professionals from different disciplines and organisations to come together and work as a team is going to require trust, respect and mutual understanding – and this can be particularly challenging given the very different cultures that exist in different health and care settings and the very different training that the staff may have undergone. 

It follows that a history of previous cross-boundary working and relationship building can make a big difference in helping to reshape services within a locality. Take the Greater Manchester Devolution Deal, in which the combined authority took control of the £6bn spent on health and social care in the ten boroughs, with the explicit aim of integrating services to meet patients’ mental, physical and social needs in a coordinated manner. While the last few years have seen some high-level developments such as the creation of a joint commissioning board for health and social care, equally important has been Manchester’s strong sense of place, community and local pride and evaluations have shown how over 30 years of building relationships and mutual trust have been a key enabler. While most of the new ICSs won’t have 30 years to build their relationships, it doesn’t mean this will be any less vital. 

The panellists also highlighted how underpinning both strong relationships and a sense of common purpose are ‘shared spaces’ to bring people together and connect them. The Mental Health Crisis Big Room is one example, where anyone involved in the crisis pathway from A&E doctors and psychiatrists to social workers and the police come together for a weekly coached meeting to tackle complex problems collectively. 

Such spaces help to reframe perceptions and initiate conversation allowing people to put away differences and work towards a shared goal. As Mark Hamilton from Surrey Heartlands ICS explained, setting principles within these spaces, such as ‘everybody counts’ and ‘we can deal with conflict and conflict can be healthy’, helps to build relationships, facilitate trust and build the confidence to take on change together.

So as the NHS Long Term Plan seeks to create ICSs across England, and as other integration agendas unfold in the devolved nations of the UK, it is important we learn from those who have done it. And while much attention will rightly be focused on the policy and structural side of change, what became clear at our Annual Event is that the line between success and failure often comes down to the ground-level human chemistry of trust, relationships and shared understandings.

Rebecca Richards is Improvement Intern and Tim Horton (@timjhorton) is Assistant Director (Insight & Analysis) in the Improvement team at the Health Foundation.

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.