Why take an ICS approach to quality improvement

Improvement is at the heart of the ICS purpose

In earlier articles in this series of blogs, we have looked at how Integrated Care Systems (ICSs) are being created to provide partnerships of health and care. We also discovered how they will plan and deliver joined up services to improve the health of people in their localities. In this article we’re going to look at how Quality Improvement (QI) is at the heart of the ICS purpose and how a QI system for ICSs could provide a great way to collaborate, inform and ultimately influence positive patient outcomes.

Let’s take a closer look. ICSs, which are due to be given legal form during 2022, have the four following key aims, which are to:

• improve outcomes in population health and healthcare
• tackle inequalities in outcomes, experience and access
• enhance productivity and value for money
• help the NHS support broader social and economic development

The Institute of Engineering and Technology's recent report 'The digital advantage: Realising the benefits of interoperability for health and social care in England’ highlights the main purpose of ICSs being to ensure quality of care for citizens - demonstrating that improvement really is at the heart of the ICS purpose, and a QI system for ICSs could really help in this regard.

In the NHS England report ‘Building strong integrated care systems everywhere: ICS implementation guidance on effective clinical and care professional Leadership’ the document identifies five core design principles, including improvement, and asks leaders to develop a framework for embedding these principles into their ICSs. They also state ‘To support implementation of this guidance, targeted improvement funding will be allocated to systems in the second half of 2021/2022,’ paving the way for great strides to be made in QI systems for ICSs.

The Department of Health and Social Care’s ‘Health and social care integration: joining up care for people, places and populations' (updated in February 2022) – talks about how interoperability and Quality Improvement for ICSs go hand in hand. While the National Quality Board Position has published a ‘Statement on Quality in Integrated Care Systems’ which focusses on ICSs’ ‘Triple Aim’ duty to deliver ‘high-quality care and put quality, including safety, at the forefront of planning and decision-making.’

The Wachter report advised that “interoperability should be built in from the start” and warns against “going too quickly” in the attempt to digitise the NHS. The report pointed to the “productivity paradox” of IT, whereby short-term return on investment is more likely to come from safety and quality, while cost savings may take 10 years or more to emerge.

With such a great focus on interoperability and improvement for ICSs, it’s really worth considering implementing a QI system that works across the board and supports ongoing Quality Improvement. Software systems like Life QI can be used to collate and analyse QI data, which in turn improves processes and decision making. Life QI is a QI project management and analysis platform which supports you in running, organising and measuring all your improvement work in one place.  The solution supports NHS and other organisations to measure impact and supports change.

A joined-up approach is essential for population health: How population health is a multi-agency challenge

Population health really is a multi-agency challenge and necessitates ‘joined up’ digital care and interoperability to succeed.  The Institute of Engineering and Technology's recent report 'The digital advantage: Realising the benefits of interoperability for health and social care in England’ points out that healthcare providers have struggled with interoperability when using multiple IT systems.

It goes on to say: ‘The problem grows exponentially as the number of systems supporting administrative and clinical processes within a healthcare provider increases and it gets even bigger when these providers are required to share information. Yet achieving interoperability is becoming ever more critical as we move towards statutory integrated care systems, through proposed legislation that has been drafted by the Government. While we have achieved significant success in a few narrowly defined areas, resolving the majority of interoperability challenges continues to elude us – as it has for over 30 years.’

This is another example of where a QI system for ICSs could really help support Quality Improvement.

With NHSX and NHS Digital driving the digital transformation of care and encouraging timely access to data, they will be relying on systems that enable providers to identify patients at risk, from their online healthcare records and deliver tailored services around prevention and earlier detection.

Population health management requires a joined-up approach and ways of working as ‘real-time insights from joined-up, aggregated data can support multi-disciplinary working, clinical decision support, waiting list management and make the best use of new diagnostic centres in the community.’

The National Quality Board’s ‘Statement on Quality in Integrated Care Systems’ shares its refreshed ‘Commitment to Quality’ and provides a common definition and vision of quality for those working in health and care systems. ‘The refreshed version has been co-produced with systems and people with lived experience. It uses the existing Darzi-based definition of high-quality care as being safe, effective and providing a positive experience, with a greater emphasis on population health and health inequalities’.

In the Department of Health and Social Care’s 'Health and social care integration: joining up care for people, places and populations' the intent is thus: ‘We will take an ‘ICS first’ approach. This means encouraging organisations within an ICS to use the same digital systems, making it easier for them to interact and share information and providing care teams working across the same individual’s pathway with accurate and timely data. Where necessary, we will intervene with ICSs and vendors – including by setting conditions of funding, producing guidance, providing support, encouraging disruption and leveraging other allies. This will allow ICSs to provide the best possible support to the places they contain, and the leaders of place-based arrangements.’

In the same report, the authors state that Integrated Care Boards are expected to ‘agree a plan for embedding population health management capabilities and ensuring these are supported by the necessary data and digital infrastructure, such as linked data and digital interventions.’ The report goes on to say that ICSs will use population health management to predict and deliver personalised care based on an individual’s risk. This will include using the wider determinants of health, recognising that factors outside of health and social care can impact patient outcomes.

Population health should take in a range of factors which must include ‘information about people’s living circumstances – for example, homelessness or social isolation. The inclusion and transparency of workforce, operational capacity, and financial data across an ICS can also support better use of scarce resources and improve productivity.’

A joined-up approach is essential for population health: Requirement to involve beyond the NHS to tackle social determinants of health

The Department of Health and Social Care’s 'Health and social care integration: joining up care for people, places and populations' backs up the importance of population health management, saying: ‘The goals of different parts of the system are not always sufficiently aligned to prioritise prevention, early intervention and population health improvement to the extent that is required. That needs to be our focus if we are to continue building better health, tackling unjustifiable disparities in outcomes, and ensuring the sustainability of the NHS and other public services.’

In the King's Fund blog: 'Integrated care systems explained: making sense of systems, places and neighbourhoods' the author talks about ICSs and how they will have the power to enable improvements in population health and to tackle those health inequalities by working with local authorities and other partners. By doing so, they will address social and economic determinants of health. The author goes on to say that ‘Evidence consistently shows that it is the wider conditions of people’s lives – their homes, financial resources, opportunities for education and employment, access to public services, and the environments in which they live – that exert the greatest impact on health and wellbeing.’

The same blog talks widely around the case for collaborative working in the new health and care systems – and how Covid-19 has strengthened the way that people work together, in order to face the huge challenges. The author highlights the importance of working ‘beyond the NHS’ and how this has enabled the ‘continued provision of essential services and to support people to remain well in their communities. Many health and care leaders emerged from the initial stages of the pandemic with renewed conviction about the benefits of collaboration and a determination to keep hold of and build on the progress made.’

It is clear that a joined-up approach and collaboration is vital for making population health management work. It includes using digital healthcare and connected health records to inform population health management and analytics.

System-wide changes still require small local changes: Small local tests of change designed within the wider system context are still the foundation of realising system-wide changes.

When looking at system-wide change across the NHS, some may overlook the fact that smaller, local changes can be equally effective, as these are the foundation of realising those bigger, system-wide changes. In its presentation ‘7 Spreadly Sins’ the Institute for Healthcare Improvement (IHI) identified what not to do for those trying to spread healthcare improvement projects. It recommends starting with small, local tests using PDSA cycles which are key to making and testing improvement QI changes.

We’ve looked at how to make small changes which can help test system-wide in other blogs. If you want to dive into a bit more detail, read our ‘Design and test changes using PDSA cycles’ article. PDSAs are recommended in Quality Improvement as they help you thoroughly evaluate and test your ideas using a structured, four step method – rather than diving in with a large pilot and no preparatory work or measures. 

Understand the system, design and test locally, share and spread what works

When you are looking at sharing Quality Improvement – it really helps to understand the system. Life QI helps you test and design your QI projects locally, while sustaining gains with an infrastructure to support them.

There are also plenty of other reports that show you how to sustain your QI changes once you have deployed and tested your solution locally, such as the BMJ Open Quality paper: ‘Quality Improvement Project Guide’. Other ways you can check your methods are working, is by creating an implementation plan which will help you to sustain the gains and incorporate them into your processes. Take a look at the template we’ve created that you can download here.

We have explored how improvement is at the heart of the ICS purpose, and how recognised improvement methodology can help support changes to population health management and quality improvement. With processes and systems in place - and means with which to check progress - you can be ready to face any challenges in your QI journey.

We will finish with the words from the King’s Fund report ‘Embedding a culture of quality improvement’, when one of its roundtable participants said: ‘It’s striking how relatively few trusts have a recognisable improvement methodology. Those that do, seem to be thriving. I think we ought to get to the point where it’s the norm.'