Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
BMJ Open. 2023 Feb 8;13(2):e065993. doi: 10.1136/bmjopen-2022-065993.
Integrated Care Systems (ICSs) mark a change in the English National Health Service to more collaborative interorganisational working. We explored how effective the ICS form of collaboration is in achieving its goals by investigating how ICSs were developing, how system partners were balancing organisational and system responsibilities, how partners could be held to account and how local priorities were being reconciled with ICS priorities.
We carried out detailed case studies in three ICSs, each consisting of a system and its partners, using interviews, documentary analysis and meeting observations.
SETTING/PARTICIPANTS: We conducted 64 in-depth, semistructured interviews with director-level representatives of ICS partners and observed eight meetings (three in case study 1, three in case study 2 and two in case study 3).
Collaborative working was welcomed by system members. The agreement of local governance arrangements was ongoing and challenging. System members found it difficult to balance system and individual responsibilities, with concerns that system priorities could run counter to organisational interests. Conflicts of interest were seen as inherent, but the benefits of collaborative decision-making were perceived to outweigh risks. There were multiple examples of work being carried out across systems and 'places' to share resources, change resource allocation and improve partnership working. Some interviewees reported reticence addressing difficult issues collaboratively, and that organisations' statutory accountabilities were allowing a 'retreat' from the confrontation of difficult issues facing systems, such as agreeing action to achieve financial sustainability.
There remain significant challenges regarding agreeing governance, accountability and decision-making arrangements which are particularly important due to the recent Health and Care Act 2022 which gave ICSs allocative functions for the majority of health resources for local populations. An arbiter who is independent of the ICS may be required to resolve disputes, along with increased support for shaping governance arrangements.
综合护理系统 (ICSs) 标志着英国国民健康服务体系 (NHS) 向更加协作的跨组织工作方式转变。我们通过调查 ICSs 的发展方式、系统合作伙伴如何平衡组织和系统责任、如何对合作伙伴进行问责以及如何协调地方优先事项与 ICS 优先事项，来探讨 ICS 合作形式在实现其目标方面的有效性。
我们在三个 ICS 中进行了详细的案例研究，每个 ICS 都由系统及其合作伙伴组成，使用访谈、文件分析和会议观察。
地点/参与者：我们对 ICS 合作伙伴的主任级代表进行了 64 次深入的半结构化访谈，并观察了 8 次会议（案例研究 1 中有 3 次，案例研究 2 中有 3 次，案例研究 3 中有 2 次）。
协作工作受到系统成员的欢迎。地方治理安排的协议仍在进行中，具有挑战性。系统成员发现很难平衡系统和个人责任，担心系统优先事项可能与组织利益相悖。利益冲突被视为固有存在的，但协作决策的好处被认为超过了风险。有多个例子表明，系统之间和“地方”之间正在开展工作，以共享资源、改变资源分配和改善伙伴关系。一些受访者报告说，他们不愿意在协作中处理困难问题，并且组织的法定责任允许他们“回避”系统面临的困难问题，例如就实现财务可持续性采取行动。
在同意治理、问责和决策安排方面仍存在重大挑战，特别是由于最近的 2022 年《健康和护理法案》赋予了 ICSs 对大多数当地人口的健康资源进行分配的职能。可能需要一个独立于 ICS 的仲裁者来解决争议，同时还需要增加对塑造治理安排的支持。
