SCIROCCO tool

Readiness to Change

If the existing systems of care need to be re-designed to provide a more integrated set of services, this will require change across many levels, the creation of new roles, processes and working practices, and new systems to support information sharing and collaboration across care teams. This will be disruptive and may be viewed negatively by workers, press and public, so a clear case needs to be made for those changes, including a justification, a strategic plan, and a vision of better care.

• Creating a compelling vision, with a real sense of urgency, and enlisting stakeholder support including political leadership, management, care professionals, public and press.
• Accepting the reality that care systems are unsustainable and need to change.
• Considering the need to address the risk of health and social inequalities.
• Publishing a clear description of the issues, the choices that need to be made, and the desired future state of the care systems, stating what will be the future experience of care.
• Creating a sense.

Structure & Governance

The broad set of changes needed to deliver integrated care at a regional or national level presents a significant challenge. It needs multi-year programmes with efficient change management, funding and communications, and the power to influence and (sometimes) mandate new working practices. This means alignment of purpose across diverse organisations and professions, and the willingness to collaborate and put the interest of the overall care system above individual incentives. It also means managing the introduction of technology-enabled care services in a way that makes them easy to use, reliable, secure, and acceptable to care professionals and citizens alike.

• Enabling properly funded programmes, including a strong programme, project management and change management; establishing digital competence centres to support roll-out; distributed leadership, to reduce dependency on a single heroic leader; excellent communication of goals, progress and successes.
• Managing successful digital innovation within a properly funded, multi-year transformation programme.
• Considering the need to address the risk of health and social inequalities.
• Establishing organisations with the mandate to select, develop and deliver digital services.

Digital Infrastructure

Integrated care requires data-sharing across diverse care teams. It leads progressively to systems that enable continuous collaboration, and the measurement and management of outcomes. This means building on existing digital care infrastructure in new ways to support integration and augmenting them with new capabilities such as enhanced security and mobility. The task can be made easier if the number of different systems in use, and the formats in which they exchange and store data, can be simplified.

• ‘Digital-first’ policy (i.e. move face-to-face communication to digital services to reduce dependence on staff and promote self-service).
• Availability of essential components (ICT infrastructure) to enable data-sharing.
• Consolidation and standardisation of ICT infrastructure and solutions; fewer technical integration points to manage; interoperability and procurement.
• Data protection and security designed into patient records, registries and online services.
• Enabling new channels for healthcare delivery and new services based on advanced communication and data processing technologies.

Funding

Changing systems of care so that they can offer better integration requires initial investment and funding; a degree of operational funding during the transition to the new models of care; and on-going financial support until the new services are fully operational and the older ones are de-commissioned. Ensuring that initial and on-going costs can be financed is an essential activity that uses the full range of mechanisms from regional/national budgets to ‘stimulus’ funds, European Union investment funds, public-private partnerships (PPP) and risk-sharing mechanisms.

Process Coordination

Health and social care delivery is a complex series of processes that are linked and interact together to achieve specified outcomes. Care coordination of these processes demands new pathways and services to improve the quality and efficiency of care and avoid unnecessary variation. The need for coordination increases when patient care requires the intervention of different professionals. Care pathways are widely used for a structured and detailed planning of the care process, including care standards. Standards’ setting, and use varies among process components. Professionals and organisations can adhere to the standards voluntarily, or they can comply with legal regulation.

Process coordination enables effective deployment and scaling up of integrated care by:

• Developing new processes and pathways that are replicable, funded and/or reimbursed, and agreed by pertinent stakeholders.
• Including an explicit statement of the goals and key elements of care.
• Defining evidence-based guidelines and agreeing on plans for formal introduction and scaling-up new services into practice.
• Negotiating with a broad range of experts and authorities the introduction and deployment of measurable care standards.
• Safeguarding the sustainability of new services and pathways.

Removal of Inhibitors

Even with political support, funded programmes and good eHealth infrastructure, many factors can still make integrated care difficult to deliver, by delaying change or limiting how far change can go. These include legal issues with data governance, resistance to change from individuals or professional bodies, cultural barriers to the use of technology, perverse financial incentives, and lack of skills. These factors need to be recognised early, and a plan developed to deal with them, so as to minimise their impact.

• Actions to remove barriers: legal, organisational, financial, skills considering the need to address the risk of health and social inequalities.
• Changes to the law concerning e.g., medical acts, information governance, data sharing –factors which may hold up innovation.
• Creation of new organisations or collaborations to encourage cross-boundary working (‘normative integration’).
• Changes to reimbursement to support behavioural change and process change.
• Education and training to increase understanding of innovations and technology-enabled care solutions in order to speed up solution delivery.

Population Approach

Integrated care can be developed to benefit those citizens who are not thriving under existing systems of care, in order to help them manage their health and care needs in a better way, and to avoid emergency calls and hospital admissions and reduce hospital stays. This is a practical response to meeting today’s demands. Population health goes beyond this and uses methods to understand where future health risk (and so, demand) will come from. It offers ways to act ahead of time, to predict and anticipate, so that citizens can maintain their health for longer and be less dependent on care services as they age.

• Understanding and anticipating demand; meeting needs better and addressing health and social inequalities.
• Improving the resilience of care systems by using existing data on public health, health risks, and service utilisation.
• Taking steps to divert citizens into more appropriate and convenient care pathways based on user preferences.

Citizen Empowerment

Health and social care systems are under increasing pressure to respond to demands that could otherwise be handled by citizens and carers themselves. The evidence suggests that many individuals would be willing to do more to participate in their own care if easy-to-use services, such as appointment booking, self-monitoring of health status, and alternatives to medical appointments, were available to them. This means providing services and tools that enable convenience, offer choice, and encourage self-service and engagement in health management, considering the need to address the risk of health and social inequalities.

Evaluation Methods

As new care pathways and services are introduced to support integrated care, there is a clear need to ensure that the changes are having the desired effect on quality of care, cost of care, access and citizen experience. This supports the concept of evidence-based investment, where the impact of each change is evaluated, e.g. by health economists working in universities or in special agencies. Health technology assessment (HTA) is an important method here and can be used to justify the cost of scaling up of integrated care to regional or national level.

• Establishing baselines (on cost, quality, access etc.) in advance of new service introduction.
• Systematically measuring the impact of new services and pathways using appropriate methods (e.g., observational studies, incremental improvement, clinical trials).
• Generating evidence that leads to faster adoption of good practice.

Breadth of Ambition

Integrated care includes many levels of integration, such as integration between primary and secondary care, of all stakeholders involved in the care process, or across many organisations. It may be developed simply for healthcare needs (i.e., vertical integration) or it may include social workers, the voluntary sector, and informal care (i.e., horizontal integration). The broader the ambition, the more numerous and diverse the stakeholders who have to be engaged. Similarly, integration may include all levels of the system or may be limited to clinical information sharing. The long-term goal should be fully integrated care services which provide a complete set of seamless interactions for the citizen, leading to better care and improved outcomes.

• Integration supported at all levels within the healthcare system – at the macro (policy, structure), meso (organisational, professional) and micro (clinical) levels.
• Integration between the healthcare system and other care services (including social, voluntary, informal, family services).
• Seamless transition for the patient between and within care services.

Innovation Management

Many of the best ideas are likely to come from clinicians, nurses and social workers who understand where improvements can be made to existing processes. These innovations need to be recognised, assessed and, where possible, scaled up to provide benefit across the system. At the same time, universities and private sector companies are increasingly willing to engage in open innovation, and innovative procurement, in order to develop new technologies, test process improvements and deliver new services that meet the needs of citizens. There is also value in looking outside the system to other regions and countries that are dealing with the same set of challenges, to learn from their experiences. Overall, this means managing the innovation process to get the best results for the systems of care and ensuring that good ideas are encouraged and rewarded.

• Adopting proven ideas faster.
• Enabling an atmosphere of innovation from top to bottom, with collection and diffusion of best practice.
• Learning from inside the system, as well as from other regions, to expand thinking and speed up change.
• Involving regional health and social care authorities, universities and private sector companies and other sectors in the innovation process (i.e., ‘open innovation’).
• Using innovative procurement approaches (Pre-Commercial Procurement, Public Procurement of Innovation, Public/Private Partnerships, Shared Risk, Outcome-Based Payment).
• Using European projects and partnerships (e.g., Horizon 2020, European Regional Development Funds, European Social Investment Funds and other).

Capacity Building

Capacity building is the process by which individual and organisations obtain, improve and retain the skills and knowledge needed to do their jobs competently. As the systems of care are transformed, many new roles will need to be created and new skills developed. These will range from technological expertise and project management, to successful change management. The systems of care need to become ‘learning systems’ that are constantly striving to improve quality, cost and access. They must build their capacity so as to become more adaptable and resilient. As demands continue to change, skills, talent and experience must be retained. This means ensuring that knowledge is captured and used to improve the next set of projects, leading to greater productivity and increasing success.

• Increasing skills; continuous improvement.
• Building a skill base that can bridge the gap and ensure that the capacity needs are understood and addressed by digital solutions where appropriate.
• Providing tools, processes and platforms to allow organisations to assess themselves and build their own capacity to deliver successful change.
• Creating an environment where service improvements are continuously evaluated and delivered for the benefit of the entire care system.