Improving health care partnerships in South East London
Unboxed worked with the Integrated Care Board in South East London over 5 months. Our goal was to identify challenges and improve working practices for collaboration between clinicians in primary and secondary care. Through interviews and workshops with staff across the organisation we constructed a model of the function and challenges of collaboration.
We then engaged in a series of rapid on-the-ground projects to learn through doing. This helped us deepen our understanding and evaluate some strategies for improvement. Regular engagement through show and tells built relationships with key stakeholder groups and led to a codesign process. We used this to create a framework for working between primary and secondary care as well as a series of short and medium term interventions to support collaboration.
What we did
Problem framing
Collaborative workshops
Designing with complexity / complex systems
Codesign
Service frameworks
Prioritisation
6
South East London boroughs engaged
50+
staff present at show and tells
The challenge
NHS South East London Integrated Care Board (NHS SEL ICB) is responsible for bringing together care providers in South East London. These providers work in partnership to tackle strategic challenges in the local area and help deliver high quality care outcomes for all.
Unboxed was asked to help the ICB understand the challenges facing primary and secondary care clinicians when working together and make recommendations on how to improve this.
Background
Integrated Care Systems were introduced in 2022 and represent a new way of working for many of the people and organisations within the NHS and Local Authorities.
Historically, primary and secondary care services have operated separately, delivered by different organisations with their own systems, processes and practices. Patients tend to assume these services are connected, and are frustrated when their GP can't provide hospital appointment details or when their care is delayed because information is shared by post.
The ‘interface’ problem between primary and secondary care causes confusion amongst patients and creates cultural and communication challenges between healthcare professionals on both sides.
Enabling collaboration
"However much clinicians value collaboration with colleagues in different organisations, the demands on their time mean that opportunities to do so are rare. Unboxed was able to build trust quickly and engage them in a meaningful co-creation process"
Toby Garrood, Medical Director, South East London Integrated Care System
Our approach
There is a vast and diverse workforce of people and organisations in South East London. We started by engaging key stakeholders from the representative bodies for primary and secondary care across SEL. We asked these stakeholders to refer us to other users within their local place or at hospital trusts. This ‘snowballing’ approach coupled with a stakeholder map allowed us to hear a range of perspectives. These were not just from clinicians but also from patient representatives and wider NHS staff. Through these conversations we learned about both the challenges and opportunities for clinicians working together.
We set out two models from these conversations:
showing where working together was failing,
proposing an alternative model of what it could look like in future.
Our challenge now was to find out how to shift from the current model to the future. There was plenty of appetite to talk about the issues and plenty of diagnoses of where someone else, somewhere else could do more to help. This however, was just going to exacerbate the problem. We needed to think creatively about how to collaboratively coauthor a solution, for everyone to be part of changing the dynamics between primary and secondary care.
Research through prototyping
To discover what might work, we decided to create some prototypes. This meant getting involved with on the ground projects to help them test out an improved experience of working together at the primary and secondary care interface.
After sharing a call for projects, we shortlisted five projects that were balanced both geographically and by healthcare sector (for example, mental health). We were conscious that this work had multiple outcomes, firstly we hoped to learn about methods for change-making, but we also wanted to deliver specific outcomes, be able to get something done within timeframes and have a story to share more widely about the breadth and balance of our engagement. This meant carefully considering and communicating with projects. In the resource scarce environment we had to be careful not to overpromise and to prioritise work that fit the criteria. This was challenging, particularly in turning things around in a short period of time. It meant that lots of good ideas were left on the table for now, but this was essential to us delivering on the overall project.
Our starting point with these projects was a set of principles for working together, derived from desk research. By using these principles to guide workshops and retrospectives with teams, we learned what was helpful and what was not. We were also able to surface more specific symptoms of a challenging collaboration environment.
It was important for us to create outputs that people working in the NHS could actually use. Based on everything we’d learnt, we formulated and refined our principles, adding a simple framework of tangible actions for each stakeholder. We set out a clear, prioritised list of challenges to be tackled and included some initial targets to build momentum and trust in change.
What we learnt
This project offered us an opportunity to engage directly with organisational design in a highly complex and evolving environment. We knew that this would bring challenges and took the opportunity to learn about these.
For example, getting engagement was hard. We were working across a large organisation with many people holding multiple roles. We found we could best work with those who had time formally set aside for the project. Throughout the work there was a necessity to go with those willing and able to take part. This presented a challenge as the sample we had was biassed against the most stressed and under pressure people across the organisation. We ensured we communicated this limitation as part of our work but believe that whilst there is likely still more to be understood about needs at the coalface we were able to get a wide reach and seed change across each part of the ICB.
We learnt that people in these roles can experience ‘change fatigue’ and confusion from being constantly asked to do things differently. This can make people more sceptical of any new project or intervention.
It was important to also guard against bias in our sample - we didn’t just want to hear the loudest voices or the people who had the most time.
From this project, Unboxed have set out some recommendations for working in complex environments in healthcare as a result:
ensure you have access to those who you need to collaborate with. We ended up doing more work with the people who had the most time and enthusiasm so we had to carefully consider what this meant for our insights
find different ways to show your work. We found Show and Tells were increasingly useful as a forum for disseminating information, though we faced some scepticism when getting them off the ground. By repeatedly explaining our process and showing how we were using what we learnt, we gradually built momentum. By the end, we were getting 50+ attendees setting aside time to join - a huge achievement for this kind of project.
in project planning, try to get a budget to support someone’s time. We’ve often found this in the NHS - busy people with multiple roles find it hard to engage with ‘new’ things unless they have the headspace and time to participate at a meaningful level.
Beyond the project
The ICB is now in the process of tackling the challenges we outlined, working through the framework and informed by the principles. We’ve built a community of engaged colleagues who have taken part in the work and are able to keep promoting it within their own areas.
Discover the framework!
Curious to explore the framework Unboxed developed from this project? We’d love to share it with you. Reach out to us today and let’s make it happen.
