HSCI Guidance: Facilitating the Journey of Integration

2. Development Exercises

DEVELOPMENT EXERCISE 1 - MAPPING OUR INTEGRATION JOINT BOARD

MAPPING OUR INTEGRATION JOINT BOARD

This exercise is to highlight where the key relationships are between the Health and Social Care Partnership and the other planning and delivery organisations that contribute to health and social care.

Given that the Integrated Joint Board sits within a complex system with different relationships with other organisations, this exercise has been developed to explore what that may mean to the Integration Joint Board members.

Activity

Ask the Integration Joint Board members to work in small groups to draw the partnership and where it sits in relation to the NHS Board, the Local Authority, the Community Planning Partnership and any other significant delivery organisations.

Use discs or other shapes to represent the organisations or draw them freehand. Then using tracing paper put a layer over the shapes and then draw in the relationships, reporting and communication channels between the partnerships and the other organisations.

• What does this map look like?
• Is there agreement in the group and across the groups?
• Is there a common perspective that emerges?
• How does this relate to me as an Integration Joint Board member?

Notice how much agreement there is on the relationships and where organisations sit, discuss different perspectives. Is there a common perspective that emerges?

DEVELOPMENT EXERCISE 2 -NATIONAL HEALTH AND WELLBEING OUTCOMES

Successful health and social care integration will be measured against the nationally agreed outcomes.

These outcomes, set out below, should be the focus for all the work of the Integration Joint Board.

1. People are able to look after and improve their own health and wellbeing and live in good health for longer.

2. People, including those with disabilities or long term conditions, or who are frail, are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community.

3. People who use health and social care services have positive experiences of those services, and have their dignity respected.

4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services.

5. Health and social care services contribute to reducing health inequalities.

6. People who provide unpaid care are supported to look after their own health and wellbeing, including reducing any negative impact of their caring role on their own health and wellbeing.

7. People who use health and social care services are safe from harm.

8. People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide.

9. Resources are used effectively and efficiently in the provision of health and social care services.

The National Health and Wellbeing Outcomes Framework has been published and can be accessed here.

The accompanying measurement framework which supports the Integration Joint Board to identify the indicators that are appropriate to them can be accessed here.

DEVELOPMENT EXERCISE 2 - NATIONAL HEALTH AND WELLBEING OUTCOMES

NATIONAL HEALTH AND WELLBEING OUTCOMES

The use of outcomes in measuring success will be familiar to some Integration Joint Board members and not so familiar to others. Each Integration Joint Board will select the indicators that they will use to show whether an outcome is being achieved or worked towards.

It is crucial that Integration Joint Board members understand what the outcomes are and how they will be achieved, but also that they should be the focus of the partnership.

• Are Integration Joint Board members comfortable about the difference between an outcome, input, output and process?
• How do Integration Joint Board members know if the indicators the Integration Joint Board are using let them know the real extent to which national outcomes are being met?
• How are these high level outcomes translated into something meaningful for your Integration Joint Board to tackle?

DEVELOPMENT EXERCISE 3 - THE PRINCIPLES OF INTEGRATION

The integration planning and delivery principles are the lens through which all integration activity should be focused to achieve the national health and wellbeing outcomes. They set the ethos for delivering a radically reformed way of working and inform how services should be planned and delivered in the future.

The principles also set a clear tone for both the national guidance and local implementation of the Public Bodies (Joint Working) (Scotland) Act 2014.

The main purpose of the integration planning and delivery principles is to improve the wellbeing of service-users and to ensure that those services are provided in a way which:

• Are integrated from the point of view of service-users
• Take account of the particular needs of different service-users
• Takes account of the particular needs of service-users in different parts of the area in which the service is being provided
• Take account of the particular characteristics and circumstances of different service-users
• Respects the rights of service-users
• Take account of the dignity of service-users
• Take account of the participation by service-users in the community in which service-users live
• Protects and improves the safety of service-users
• Improves the quality of the service
• Are planned and led locally in a way which is engaged with the community (including in particular service-users, those who look after service-users and those who are involved in the provision of health or social care)
• Best anticipates needs and prevents them arising
• Makes the best use of the available facilities, people and other resources

Guidance on the planning and delivery principles which describe how integrated care should be planned and delivered and how the principles will work in tandem with the National Health and Wellbeing Outcomes can be accessed here - Integration Planning and Delivery Principles.

DEVELOPMENT EXERCISE 3 - THE PRINCIPLES OF INTEGRATION

PRINCIPLES OF HEALTH AND SOCIAL CARE INTEGRATION

The following statements have been developed to help Integration Joint Boards consider how well they are embedding the principles of integration.

As an Integration Joint Board , each member should indicate where they feel their board sits on the following statement with 1 strongly agree and 5 strongly disagree

The Integration Joint Board should collectively look at the responses and;

• consider the differences and similarities
• reflect on what they might mean
• identify potential areas and opportunities for improvement

Please give a rank to the domains below in terms of the development required by the Integration Joint Board	Scale: 1 = Strongly agree to 5 = Strongly disagree
Focus on service users The Integration Joint Board is assured that the needs of individual service users are met with respect, dignity and safety.	1	2	3	4	5
Focus on communities The Integration Joint Board is assured that the services developed and delivered within their localities reflect full engagement with their communities and will deliver improved outcomes for local people.
Resources and accountability The Integration Joint Board is confident that it will deliver on its strategic priorities, effectively manage associated risks and that it makes the best use of available resources.
Board dynamics Integration Joint Board members are motivated individuals who have the right blend of skills and experience to help deliver the strategic intent. Board members work constructively together in a climate characterised by informed trust, involvement and robust dialogue.
Leadership The Integration Joint Board is confident that it has the conditions to support collaborative leadership and that every member's voice is heard and valued.

DEVELOPMENT EXERCISE 4 - THE ROLE OF AN INTEGRATED JOINT BOARD AND ITS MEMBERS

The principles and outcomes that have been developed for integration are designed so that the people in your communities have the best possible services which are tailored to local circumstance and deliver high quality results. The role of Integration Joint Board member is to ensure that this is central to the decision-making process.

Making decisions about how integrated health and social services are planned and delivered for communities both now and in the future presents Integration Joint Boards with their most significant challenge but it also has huge opportunities for all parties. Working with complex multi-faceted problems will require a collective wisdom and approach that seeks to draw on all the assets of the Integrated Joint Board members and the communities and groups they serve. There will be difficult decisions to be made on the journey of integration and how the Integration Joint Board approaches these will be crucial in defining its success.

It is important to acknowledge that with so many different stakeholders and interests represented on the Integration Joint Board it is likely that there will be times of disagreement from respective organisational points of view. It is therefore important to remember that when members sit on an Integration Joint Board they are representing the interests of the Integration Joint Board. They will have been nominated by their parent organisations and must act in the best interests of the Integration Joint Board. This may at times mean decisions are made that do not sit easy with colleagues in their parent organisations or indeed with communities and members of the public. It is therefore important that the principle of collective decision making is reinforced and Integration Joint Board members accept that once decisions have been agreed, they may need to function as a community leader to make sure the changes which have been agreed happen.

Constructive challenge and discussion within Integration Joint Boards is imperative. Rigorous scrutiny of proposals that are put before the Integration Joint Board will help to justify potentially difficult and unpopular decisions .Integration Joint Boards should ensure that appropriate professional advice from your fellow Integration Joint Board members and others is sought as appropriate. Adopting this approach as individuals and as a collective will enable the successful redesign of pathways of care and ensure that the co-productive nature of the Integration Joint Board is maintained.

DEVELOPMENT EXERCISE 4 - THE ROLE OF AN INTEGRATED JOINT BOARD AND ITS MEMBERS

INTEGRATION JOINT BOARD - DECISION-MAKING ARRANGEMENTS

The following issues for consideration have been developed to help Integration Joint Board discuss and reflect on decision-making arrangements. It will help clarify how Integration Joint Boards will engage with and ensure that all members contribute to the business of the board. The purpose is to generate discussion and reflection on 'how' the Integration Joint Board works together. Exploring different perspectives will enrich how the Integration Joint Board works together and forms their own ways of reaching agreement.

Issues for consideration

• How do we as an Integration Joint Board make decisions around areas where members may have different opinions?
• As an Integration Joint Board member you may be in a position where the decisions that are agreed by the board do not reflect your own views. How will you provide effective leadership in these circumstances?
• As an Integration Joint Board member you may at some point have a conflict between the goals of the Integration Joint Board and that of your parent organisation. What preparation and support can you draw on to work this through, when it occurs?
• How do we, as an Integration Joint Board, ensure transparency in our decision-making?
• How do we ensure the Integration Joint Board works collectively and 'corporately' to achieve best improved outcomes across the Health and Social Care Partnership?
• How will the Integration Joint Board hold itself to account for its decisions?
• How do we ensure the Third and Independent sectors in the Integration Joint Board feel included and involved in deliberations. How do we evidence this?
• How will we ensure engagement with relevant stakeholders not on the Integration Joint Board, and facilitate their contribution?
• How will we ensure the voices and perspectives of all members are equally considered in our decision-making processes
• How do we know if the Integration Joint Board strategy, vision and principles are collaborative and integrated?
• What difference will we notice when the Integration Joint Board vision, strategy and principles of integrations are upheld or implemented?

DEVELOPMENT EXERCISE 5 - MEMBERSHIP OF THE INTEGRATED JOINT BOARD

The job of the Integration Joint Board is to help shape the development of integrated arrangements and decide how best to plan and oversee the delivery of the functions that have been delegated to it. The Integration Joint Board is made up of voting and non-voting members. It is important to understand the following:

• Voting membership must have parity in terms of membership, the Local Authority and the Health Board who make up the voting cohort must agree on the same number of representatives to sit on the Integration Joint Board.
• The Integration Joint Board must have a minimum membership which is outlined in the Public Bodies (Joint Working) (Integration Joint Board) (Scotland) Order 2014.
• The Integration Joint Board can add additional non-voting members to the Board if there is agreement.

It will be important for Integrated Joint Board members to have a clear understanding of the the role they hold and those of other members of the Integration Joint Board. Below is a description of the varying roles that must make up the membership of an Integration Joint Board

Local Authority and NHS Members (Voting members)

These members are nominated in equal numbers by the Health Board and Local Authority. Their role is to bring the perspectives of their parent organisation onto the Integration Joint Board and help shape the strategic direction of the Integration Joint Board to improve outcomes for their communities.

Advisory Members (Non-voting)

The non-voting members of the Integration Joint Board are there to provide advice and support to ensure that the integration of services makes a difference for the people using them and being supported by them

• Chief Officer of the Integration Joint Board is the single point of accountability for integrated services. They are appointed by the Integration Joint Board and are responsible for the development, delivery and oversight of the Integration Joint Boards Strategic Plan.
• The Section 95 Officer (Chief Financial Officer CFO) of the Integration Joint Board is statutorily responsible for the financial assurance and accountability of the Integration Joint Board.
• The Chief Social Work Officer of the constituent Local Authority has the statutory responsibility with regards to the governance of social care services.
• A General Practitioner, appointed by the Health Board, is required to provide advice to the Integration Joint Board on matters relating to primary care services and represent the GP and primary care communities.
• A Secondary Medical Care Practitioner, employed by the Health Board is required to provide advice to the Integration Joint Board on matters relating to the Secondary Medical Care and represent Secondary Medical Care Practitioner more broadly.
• A Nurse representative, employed by the Health Board; is required to provide advice to the Integration Joint Board on matters relating to nursing and represent the views of the nursing community more broadly.
• A staff-side representative is expected to provide advice on staff issues to the Integration Joint Board and to report to their membership on the topics discussed at meetings. These individuals are non-voting members of the Integration Joint Board.
• A Third Sector representative is required to provide advice to the Integration Joint Board on matters relating to Third Sector and represent the views of the Third Sector more broadly.
• A carer representative; is required to provide advice to the Integration Joint Board on matters relating to carers and represent the views of the carers community more broadly.
• A service user representative; is required to provide advice to the Integration Joint Board on matters relating to service users and represent the views of the service users more broadly

DEVELOPMENT EXERCISE 5 - MEMBERSHIP OF THE INTEGRATED JOINT BOARD

BUILDING RELATIONSHIPS

The following issues for consideration have been developed to help the Integration Joint Board discuss and reflect on how they will develop and build effective relationships to deliver the vision and principles of integration. They can be used in a variety of ways, through paired discussions, group discussion or whole board reflection. However they choose to use them, the purpose is to build trust, communication and understanding between Integration Joint Board members.

• What do we value about working in partnership?
• What is important to us in working together, what do we need to be present?
• How do we demonstrate the principles for integration in how we work?
• What might get in the way of this and how would we deal with these situations?
• What people skills are important for us in these roles?
• What does effective collaboration look and feel like as an Integration Joint Board member?
• How will we build trust across the Integration Joint Board, what are our /my roles in this?
• How will we work with challenge, difference or disagreement to reach decisions that improve outcomes for people?
• If we get 'stuck' how will we notice this and move forward?
• Where will we seek help and support to help us to continually develop?
• How will we recognise and celebrate success?

DEVELOPMENT EXERCISE 6 - ORGANISATIONAL CULTURE

Bear in mind that all Integration Joint Board members will come from different organisations, some with political backgrounds and alliances.

The issues that an Integration Joint Boards will face will be challenging and it is essential that in taking this forward the business of the Integration Joint Board it is conducted in line with the Ethical Standards in Public Life etc. (Scotland) Act 2000.

CULTURE OF THE INTEGRATION JOINT BOARD

Public, Third and Independent Sector services have very different; ever changing and evolving cultures

The culture of Integration Joint Board will be different from members 'parent' organisations in that it will be bringing together a variety of cultures. The challenge for the Integration Joint Boards will be to bring the best from these existing cultures and establish the essential elements within Integrated Joint Boards as they plan and commission integrated services.

There are lots of different elements that shape culture. The following questions have been developed to prompt discussion across the Integration Joint Board membership to help them to acknowledge culture differences, celebrate what is good already about culture and how they can help to shape new culture.

• What are the symbols which mark a healthy work culture?
• What do we want to highlight as important now?
• What are the aspects of our culture that we wish to focus on?
• How do we model these aspects in our leadership role?
• Do we understand our informal culture creators?

DEVELOPMENT EXERCISE 7 - LEADERSHIP

The leadership role of a member of the Integration Joint Board is complex; invariably requiring members to juggle competing demands and deal with complex situations. Some of the skills required to successfully fulfil the role of an Integration Joint Board member include collaborative and collective working, self-awareness and astute governance.

In relation to meeting governance and accountability expectations, maintaining a focus on the national outcomes for people will enable these commitments to be met. In working this way as an Integration Joint Board will be able to have confidence in knowing that people's needs are clearly at the centre of service design and delivery rather than services driving activity. This guide provides a focus for Integrated Joint Board members to consider what skills they may have and need to contribute, in order to support the Integration Joint Board to work in this way.

To achieve the vision of integration, where people are at the centre of delivery, leadership is required at all levels. It is crucial that the Integration Joint Board are able to lead by example and model the kind of inclusive, collaborative and person-centred behaviour expected from practitioners and organisations. It is recognised in research that the focus and priorities of the board will have an impact on the quality and delivery of care. The role of an Integration Joint Board member is fundamental in establishing the future vision and culture change required to support integration.

It is important to understand people, what matters to them and why. Being self-aware will enable Integrated Joint Board members to first understand their strengths and what drives them, how they relate and react to others personally and professionally, how they process information and the ways in which this informs how they reach conclusions and take action.

DEVELOPMENT EXERCISE 7 - LEADERSHIP

LEADERSHIP

To enable effective relationships it is important that you consider the following questions:

• What do individual members bring to Integration Joint Board?
• What do the other Integration Joint Board members bring?
• What will the Integration Joint Board do together that will make a difference to people?

Effective relationships are at the heart of effective organisations. The core of developing relationships is building trust and understanding across the members of the Integration Joint Board.

The space for listening to what is important to individuals may seem like a luxury or indulgence, however it has the potential to pay dividends in terms of time saved and problems avoided through the Integration Joint Board having a high degree of trust. Working together with other Integration Joint Board members to deliver effective leadership and create resilient relationship is crucial and requires building trust through honest relationships and maintaining clarity of role and purpose.

DEVELOPMENT EXERCISE 8 -WORKING TO SUPPORT LOCALITIES

One of the key components of the Public Bodies (Joint Working) (Scotland) Act 2014 is that it requires the establishment of localities, so what does establishing localities mean for the Integration Joint Board?

Within each Health and Social Care Partnership there will be at least two localities, although partnerships can have more if they wish. Localities will be shaped differently across Scotland; however the guiding principle that Integration Joint Board members must remember is that localities are in place to enable services to be tailored to local circumstance.

Integration Joint Boards must ensure that the rationale for identifying localities is sound and robust. Localities should relate to natural communities and take account of clusters of GP practices and levels of deprivation and health inequalities. The key to the success of localities is the involvement of different participants: GPs primary care, secondary care, social care and most importantly local communities all have a role to play. Therefore, members of Integration Joint Boards must ensure that the rationale for developing localities is sound, it is even more important that skills and insights of these key groups are successfully heard. Drawing on the expertise of the professional advisors to the Integration Joint Board and having close links with Community Planning Partnerships will support Integration Joint Boards to do this.

Localities and partnerships need to develop in tandem with decisions about local resource being made as close to the locality as possible. Localities should have the ability to allocate resources and enable close community and workforce involvement to support innovation and service design to meet local needs. Engagement of professionals, including primary care will be a key element of in developing thriving and effective locality working.

In addition, the establishment of localities puts in place certain legal requirements and Integration Joint Board members should make themselves aware of these as localities are developed.

For further information in relation to localities, Integration Joint Board members can refer to the All Hands on Deck, the think piece previously published by the Scottish Government on the importance of localities.

DEVELOPMENT EXERCISE 8 -WORKING TO SUPPORT LOCALITIES

WORKING ACROSS LOCALITIES

The reflective questions and issues for consideration below are designed to support a discussion across the Integration Joint Board. Notice what is similar and different in perspectives. What does this mean for the Integration Joint Board? What are the agreed areas for development?

Reflective questions

• Although each locality will be unique, are there common priorities across them all?
• How does the Integration Joint Board respect different locality needs in our decision-making?
• Does the Integration Joint Board have effective engagement with primary care and the wider workforce within our localities? How is this being evidenced?
• What conditions will enable decision-making and resource transfer to localities?
• What does it mean for the Integration Joint Board if priorities in the localities are widely different and conflicting?
• How can the principles for integration help us be flexible and adaptive?
• How flexible/responsive are we able to be if priorities change locally?
• How confident do Integration Joint Board members feel about their knowledge and understanding of the communities in the partnership area?
• How does the Integration Joint Board ensure that engagement with the communities is effective in each locality?

DEVELOPMENT EXERCISE 9 - STRATEGIC COMMISSIONING PLANS

The Act places a duty on Integration Authorities to develop a "strategic plan" for integrated functions and budgets under their control. The strategic plan is the output of what is more commonly referred to as the "strategic commissioning" process.

Strategic commissioning is the term used for all the activities involved in assessing and forecasting needs, linking investment to agreed desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place^[1].

Each Integration Authority must produce a strategic commissioning plan that sets out how they will plan and deliver services for their area over a three year rolling period. All members of the Integrated Joint Board must be fully engaged in the preparation, publication and review of the strategic commissioning plan, in order to establish a meaningful co-productive approach, to deliver the national outcomes for health and wellbeing, and achieve the core aims of integration.

By developing new strategic commissioning plans for all adult care groups, Integration Joint Boards have an opportunity to design and commission services in new ways in collaboration with their partners. Strategic commissioning plans should incorporate and leverage informal, community capacity and assets to deliver more effective preventative and anticipatory interventions.

Services cannot continue to be planned and delivered in the same way. The current situation is neither desirable in terms of optimising wellbeing, nor financially viable. The focus should be less about how it is done now and more about how it should be done in the future. This might mean, through a robust option appraisal process, that the Integration Authority makes decisions about disinvesting in current provision of services in order to reinvest in other services and supports that are required to meet on-going and changing demand.

DEVELOPMENT EXERCISE 9 - STRATEGIC COMMISSIONING PLANS

STRATEGIC COMMISSIONING PLANS

The reflective questions and issues for consideration below are designed to support a discussion across the Integration Joint Board. Members may find it useful to reflect on their own perspective then share this with others. Notice what is similar and different in how you see things. What does this mean for the Integration Joint Board? Where are your agreed areas for development?

• How will we assure ourselves that the strategic commissioning process is robust and reflects a new way of working?
• How will the Integration Joint Board negotiate amongst itself if there are areas of disagreement about the strategic commissioning process or outcome?
• Where there are areas of disinvestment, what will the process be for this and how will the Integration Joint Board communicate this message to stakeholders?
• How do the values and principles of health and social care integration challenge traditional commissioning and planning - what impacts will these have, what skills might Integration Joint Board members need to bring about positive change and outcomes?
• How will the Integration Joint Board ensure an outcomes approach to commissioning is implemented?
• How might procurement processes need to change?
• What support do we require as an Integration Joint Board to achieve this?

DEVELOPMENT EXERCISE 10 - BOARD DEVELOPMENT

Each Integration Joint Board is required to produce a Board Development Plan which sets out how the Integration Joint Board plans to develop a continuous improvement approach to how it operates.

The Board Development Plan will pull together the themes and areas for improvement as well as detail actions required and monitoring process. This exercise is just one example of these and the questions that may assist with the process of creating the plan.

ASSESSING CONTINUOUS IMPROVEMENT

The Integration Joint Board should collectively review and discuss the themes and questions and from the discussion the themes for improvement should emerge.

Themes	What are we doing well?	What do we need to change in the way we are working to improve our effectiveness as an Integration Joint Board?	What action do we need to take to make this improvement?
Focus on service users
Focus on localities
Resources and accountability
Board Dynamics
Leadership