Article

Six ways to create a culture for integration  

Six ways to help build a culture of integration for successfully integrated working.

1 September 2023

The six ways to create a culture for integration have been developed to help systems understand how they can create an environment where integrated working can thrive.  

In October 2022, we published a joint guide, integrated workforce thinking across systems which offers tips and insights to help system leaders start integrated working. The six ways build on the guide which will be referred to throughout this resource.

Since the publication of the guide, we have received feedback from members that building the right culture and creating strong relationships can sometimes be difficult to achieve but present new opportunities if done well. That is why we have created a resource prompt thinking and provide tools to create a better culture.

The six ways were drawn from systems currently planning and developing integrated working and collated by NHS Employers and Skills for Care (SfC).  

We have also engaged with a number of people to ensure that a system voice has been represented throughout the resource. Partners in Care and Health, a partnership of the Local Government Association (LGA) and Association of Directors of Adult Social Services (ADASS) have contributed to this work as well as, social care and NHS employers through an engagement session at NHS ConfedExpo.  

Building on culture  

It's important to acknowledge that ICSs are at various stages of development. Some have been established for some time, while others are just starting this journey. However, what unites all ICSs is the need for individuals from different organisations to work collaboratively to create a culture where integration can thrive.

Collaboration among organisations is not enough to create integrated working. Systems must invest time in building meaningful relationships across sectors, where each organisation understands the strengths and challenges of others. Genuine partnerships can help build a culture that truly improves the quality of life of people who draw on care and support.

In the 2023 Hewitt review, Patricia Hewitt stated: ‘ICSs represent the best opportunity in a generation for a transformation in our health and social care system. Effective change will require the combination of new structures with changed cultures. Everyone needs to change, and everyone needs to play their part.’

Hewitt also outlined the importance of creating the right culture for integration calling for health and social care to work in a collaborative way, rather than a competitive way. Creating an integrated approach to health and social care provides people in communities with a life, rather than a service.

ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services to improve the lives of those who work and live in their area. Included in ICSs are the Integrated Care Partnership (ICP), Integrated Care Board (ICB), local authorities and place-based partnerships that design and deliver integrated services across their localities or neighbourhoods.

Achieving an integrated culture in the complexity of the health and social care system can be challenging. This resource shares tips on how to work towards this goal.

Six ways to create a culture of integrated working

The six ways are practical and thought-provoking approaches to creating a culture of integrated working.

Be prepared to experiment and learn together

ICSs are developing, and they do not have all the answers. It’s important to be open to new ideas and try new things to find what is going to work. All ICSs are different so what works for one might not work for another. Not everything will work but we can learn valuable lessons from when things do not go to plan. This test-and-learn mindset can shift away from usual ways of thinking and help to shape what to try next.

A good place to start is by understanding your population’s health and social care needs to identify where your system is lacking in information. This will be helpful to gain an understanding of all its population needs workforce solutions and gaps in workforce knowledge.
Find out how Hull and North Yorkshire ICB integrated their health and social care services to establish a centre for frailty to meet the needs of their population in this case study: A place to meet the needs of people living with frailty: Jean Bishop Integrated Care Centre.

Have a clear shared vision

Person-centred care is a key principle that brings services together. From this, it is important to develop a shared purpose and agenda. Developing some objectives around what you want to deliver together can help you create a shared vision. Agree and understand that relying on the same approach will not provide the necessary results for an integrated system.

Future thinking can help system leaders, for example, imagine a day in five- or ten years, when you’ve successfully achieved integrated working. Describe what you can see, what it feels like, what conversations are happening etc.

It can be powerful to describe this from different perspectives e.g., the person with care and support needs, someone working in the system, and a leadership or organisation/system perspective.
Read this case study from One Devon: Devon ICS’ approach to integrating their workforce across the system to find out how Devon ICS established the One Devon partnership, to transform care now and for future generations.

Set the tone

Integrated working allows you to do things differently. We are all limited by our existing experiences so taking a step back to think about different approaches and how working together will encourage a shared sense of identity and belonging.

Attention should be given to identifying jargon, breaking down system speak, acronym busting and creating effective communication systems. This focus on language should be applied when developing strategies, recording minutes, sending communications, meeting discourse and inviting views and feedback. If the language used is not accessible and understandable by the person receiving care or any one part of the system, then this can cause a barrier to integrated working. Integrated working should be anchored on person-centred care.

System leaders should be role-modelling this behaviour, holding systems to account and embodying this new way of thinking.

As a group consider these discussion questions:
- What will help you come together to understand where you are trying to get to and what will help you get there? Recognise that what you’ve done before in your organisations might not be the best solution when you are working in an integrated system.
- How do you start from a strength based approach and build on the great examples that are already happening?
- How do you create spaces where people feel comfortable to suggest new and different ideas and approaches – and create a culture where people feel comfortable asking questions? Listening and valuing diverse ideas, thinking and perspectives will mean you’re more likely to get to solutions that work. Are we using the right language in these spaces and communicating in a jargon free way?
- Recognise partner differences and focus on shared goals. Foster a positive feedback culture. Make decisions together and avoid one partner dominating for a cohesive partnership. To ensure one partner does not dominate the conversation consider independent facilitation and rotate facilitation from different parts of the system.
- Access NHS Employers DoOd ‘OD practitioner and culture change’ toolkit which provides a variety of questions to inspire thinking on culture change.
- Read Michael West, senior fellow at The King’s Fund blog on psychological safety, compassionate leadership and inclusivity in teams.

Get to know each other and understand each other’s worlds

Getting to know one another increases the likelihood of successfully navigating difficult challenges and resolving issues together. Remember that you are planning for the workforce in a complex system and that no one person understands all areas of it. You need each other’s knowledge, understanding and different ideas and perspectives to be successful.

Utilise existing networks across all organisations to ensure there is a collective understanding of both social care and health. This can be done by putting on workshops/ events to raise staff awareness about what other sectors do and what they can provide. Ask the following questions:
- Do health colleagues understand how many care providers there are in their local area, what they do and how they are commissioned?
- Do you understand what each other’s roles, responsibilities, pressures and priorities are? This could be a helpful and open conversation that can lead to a productive conversation about current issues and how/if you could provide any support or advice. It might also be helpful to consider shadowing each other to gain a better understanding.
- Do social care colleagues understand how the health system works across both acute and primary health care, and what roles and responsibilities different health organisations have? Are there any networks in existence you can attend that will help you to gain knowledge on the current workforce insight?
Consider the following:
- Everyone has their own map of the local area that they live and work in. Take time to explain your map to others and ask each other questions about what is on their map. For example, some people's maps will put the local hospital at the centre of the map with everything else feeding into the hospital. Other people's maps might put a small social enterprise in the centre and not refer to the hospital. Both maps are right and opportunities for new ways of working can be seen when overlaying them when we recognise each other’s perspectives. Acknowledge the multiple cultures and identities within a shared space. Ways of working, challenges and opportunities can vary within health and social care, not just between. System partners will also wear “multiple hats” through their work and the roles they carry out. Seek to build a culture and shared space for integration which facilitates and supports this multifaceted approach.
- Do an audit of perspectives and existing ways of working. The NHS and social care have a similar size workforce but different languages, cultures, outcomes, visions and structures. The small and medium-sized enterprises-based composition of adult social care means its perspective and engagement need to be actively sought where possible. It’s worth considering the following when reviewing mechanisms of engagement:
  - who is and isn't represented?
  - How are decisions made?
  - Has everyone’s voice been heard?
  - How is information shared?
  - Has information been shared with all before the meeting?
  - What does each partner bring to the table? And is every partner at the table?
  - Is one partner dominating decision-making?
  - Co-design an approach to these questions that all feel they can sign up to.

Use data to facilitate the conversation and prompt discussion

Gaining insight into the health and social care needs of your community through population health data is an effective approach to initiate discussions and explore alternative ways to offer support.

You may feel overwhelmed by the volume of data available from parts of the system or that some of that data isn't available or it's collected in different ways. Remember that you don’t have to have all the answers and all the numbers. There is value in collective discussion and getting everyone around the table to have a conversation to increase people’s understanding of the data.

It is important to remember that the demand in each ICS will be different. Using workforce data alongside population health data can help identify workforce gaps and prepare for future demand. Considering factors such as the presence of rural or coastal areas with high retirement populations may result in increased demand for care homes and hospital admissions for fragile patients. Alternatively, if your system consists of more urban areas with higher student populations, the demand may be greater for mental health services.

By understanding the needs of your community, you can cross-reference data from across the system and identify postcodes/ people who are vulnerable and who are in extra need of support. This could draw upon Joint Strategic Needs Assessment and ICBs five year joint forward plan.

- Consider hosting a workshop to collectively make sense of what the data is telling you, and just as importantly, what it’s not telling you. But don't get paralysis by analysis, see step one.
- A good place to start for the adult social care workforce data at ICS level is the Skills for Care Tableaux which includes information on size and structure, recruitment and retention, pay, qualifications and training, analysis by care need and workforce projections. For more information on how to access this data see the size and structure of the adult social care sector and workforce in England.
- You can see a breakdown of your own ICS area or do an ICS comparison with other ICS areas. This data can be used to support workforce planning.
- Different organisations and people will have different perspectives on which data is most important. Never assume that everyone will value the same data. Ask people which data is important to them.
- Take a look at the data section in our integrated workforce thinking guide for information and links to further resources on how to provide a shared understanding of the challenges across the system.
- NHS Black Country ICB have developed their joint forward plan. Access the plan on their website.

Share your challenges and your strengths

By bringing people together from different parts of the system and providing the opportunity to set out their challenges and strengths, you achieve two important things. It will give you a good sense of where you are across the system and help to create a sense of connection between people as they recognise, they have more in common than they have that is different.

Empower people to make mistakes and to take risks acknowledging that not everything will work the first time and knowing that you need to invest a lot of time to create a better culture.

We want to hear from you

We recognise that every ICS will be at a different place in their journey, from creating a culture for integration to developing a fully integrated workforce plan. Our work relies on your insight and our cross-partnership work aims to identify emerging lessons, challenges, opportunities and best practice. Similar to your journey the guides we create are an ongoing, evolving process. We want to hear from you to help shape our work and share best practice. Tell us:

What’s your experience in creating a culture for integration?
How have you found the implementation of the six ways?
Do you have any reflections on the six ways? What do you find helpful? What’s missing?
Are there examples of best practice you would but forward on building a culture for integration?

If you have any reflections, please do not hesitate to get in contact at system.working@nhsemployers.org.

Watch our creating a culture for integrated working webinar

On 19 September, in partnership with Skills for Care and Partners in Care and Health, we hosted a webinar to hear from colleagues who have successfully created a workforce culture that champions integrated working. Speakers included, Hull and East Riding, Humber and North Yorkshire ICB who shared their journey to create a centre for frailty, Staffordshire local authority who discussed the work they have done around collaboration and listening between services and Jane Green founder of the neurodivergent charity SEDSConnective who shared her lived experience and what good culture means to service users.

Use the time stamps below to navigate to a part of the webinar you want to hear about:

02:26 - Challenges of working together

06:24 - Jean Bishop Integrated Care Centre

35:00 - SEDS Connective

42:23 - Staffordshire local authority

01:11:00 - Six ways to integrated culture

01:19:33 - Final reflections and close

The organisation, Lim captured the key outputs and takeaway tips from the webinar in the below visual:

Creating a culture for integration visual from the webinar

Our work does not seek to provide all the answers but has been designed to support all 42 ICSs to develop new integrated ways of working built on the best collective understanding we have.

Find more on system integration.