Evidence-based Interventions Across Boundaries: System Working

We have engaged with a wide range of exemplar ICSs to collate different approaches to system working in the implementation of EBI guidance. These experiences were compiled and summarised to help other systems efficiently implement best practice in the domains covered.  As such, the results are expressed in an advisory format, with an emphasis on practical advice, operational benefits to smooth the route to implementation.

The specific aims and objectives are:

1. To enable collaboration at scale within ICSs, centred around delivering the core features of EBI implementation.
2. To enhance the quality of decision making and the level of insight available to decision makers, by enabling a wider range of participants at key points. 
3. To promote efficiency and simplicity in EBI-related decision making, by enabling ICSs to consider where decisions are best made, how many times they are made, and who needs to be involved. 
4. To promote public and patient confidence in EBI-related decision making, through strategic involvement in and oversight of key decisions.
5. To optimise accountability for implementation, aligning power and influence with operational action to provide wide-ranging and senior backing – allowing key implementation agents at every level to act with confidence and system-wide authority.

The information included has both direct and indirect effects which support the uptake and implementation of NICE guidance:

1. The EBI guidance is substantially informed by NICE guidance, meaning that these proposals will support the translation of the recommendations made in NICE guidance into clinical practice. 
2. NICE guidance is pathway-oriented and spans different organisations.  By helping systems to develop and piece together the core building blocks of cross-system working, this guidance not only enables delivery of EBI guidance, but also allows for easier implementation of NICE guidance.

The EBI programme engages regularly with a range of NHS organisations.  In the course of our engagement, we discovered models of best practice in our Demonstrator Community which led to more effective delivery of EBI through collaborative planning, delivery, and oversight.  These improvements correspond to the benefits described in the preceding section but were not distributed equally across England. 

With the proposed establishment of ICSs as statutory bodies in April 2022, the timing of this publication is pertinent.  Over the next year, as CCGs transition into ICS bodies, the recommendations made will support ICSs to transcend organisational boundaries and implement guidance more unitively. The proposals can be adopted wholesale or in a piecemeal way meaning systems at varying levels of maturity can extract benefits.

Material from and engagement with multiple organisations, across thirteen geographies, was used to form this case study. The systems involved span the seven NHSEI regions and have a diverse range of populations across multiple metrics (deprivation levels, age, race and ethnicity).

For information on the specific organisations and systems involved, please see the case study itself, which is attached. 

For this case study, we systematically observed the actions ICSs had already taken to collaborate. The results can be considered in 4 categories:  

1. Governance
2. Compliance and Performance Monitoring.
3. Clinical Engagement and Policy Development.
4. Programme Management.

Please see the attached case study itself for further detail in each of these domains.  

The examples featured were self-reported by the systems involved on the basis of them leading to beneficial changes. The results and benefits of these actions can be summarised as follows:

Governance

• Building stronger relationships (e.g. through information sharing processes) with a wider range of system partners has enabled many of the benefits described above. For example, Sussex Health and Care Partnership have created a county-wide oversight committee covering EBI implementation. This includes local authorities (LAs). Issues are only escalated to this committee when they meet a set of escalation criteria, which ensures key decision makers from all organisations are used only at the most beneficial points.  
• Increased representation of alternative system actors has led to an infusion of expertise into their policy development and oversight processes, allowing for a greater understanding of technical issues (i.e. public health involvement) and adverse implementation impacts (i.e. Healthwatch identifying differential impact on specific patient populations).
• More extensive stakeholder engagement translates to higher public and patient confidence in the programme, which avoids challenge, and supports more frontline collaboration on specific implementation issues.
• Governance processes which situate EBI-related programmes at the STP/ICS-level may also unlock opportunities for inter-programme working. For example, linking EBI to mutually supportive transformation programmes irrespective of which individual organisation these are located in. 
• System-wide governance processes also increase decision-making speed and reduce duplication.

Compliance and performance monitoring

• Consistent, cross-system implementation models reduce the ICS administrative cost (doing things once rather than several times). It also reduces the administrative burden on providers who, in some systems, were needing to engage with multiple differing processes of administration.

Clinical Engagement and Policy Development

Clinical engagement approaches can also benefit from being harmonised at system level:

• As clinical priorities are often agreed at system level, a single approach to engagement aligns with clinical authority, sets a high evidence standard to support engagement and permits a wider benchmarking range.

Programme Management

• System-wide programme teams allow the STP/ICS to continually translate activities of senior management and clinical leadership to the frontline.

Our engagement shows that all systems have room for improvement in at least some of the above areas.

Using evidence from the EBI Demonstrator Community, the following sections outline practical learning for improving practice.

Governance

• Nominate an EBI lead at each trust, to encourage contributions in key governance forums.
• Delineate each stage of the policy process, from design, to development, embedding and monitoring. If the EBI variant is located at system level, ensure the programme SRO advocates for its inclusion in clinical transformation groups to feed into wider initiatives.
• Establish a Joint Committee with the seniority and expertise to create consensus and drive implementation, as well as separate STP/ICS-level sub-committees for clinical and operational issues.
• Involve local authorities, Healthwatch, and other key bodies when policy consequences can be materially assessed.

Delivery Monitoring

• Use established governance channels to secure agreement but be flexible on implementation schedules.
• Localised clinical oversight can help ensure that the population factors unique to those areas are considered in key forums.
• Where place-based needs present barriers to a common implementation approach, consider proposing a differentiated prior approval system to support buy-in.
• If the efficacy of the implementation principle is agreed, involve senior provider-based stakeholders in advocating for a consistent and simple prior approval process for the system.

Clinical Engagement and Programme Management

• At the STP/ICS level, situated the programme team between the senior decision makers and frontline programme delivery. This is a crucial step to joined up delivery and supporting system-wide policy development and implementation.
• High-performing systems have central programme teams, responsible for delivering their EBI-variant across system geographies. These teams must have; clinical oversight, analytical capability, strategic capability and engagement capability.
• Programme teams typically contain the following roles: Senior Programme Director, Programme Manager, Clinical Lead and Data and Analytics Lead.