Dorset Integrated Care System: pilot assessment report

Direction of travel

There is a positive direction of travel for quality and safety with evidence of system-wide safeguarding processes and shared workforce initiatives. However, limited development of a shared safety culture and insufficient investment in health prevention is a risk to achieving more equitable access and outcomes.

Summary of strengths

• The System Quality Group (SQG) is system focused and provides suitable oversight and assurance of system-level issues and concerns. Place-based quality and safety reporting and escalation arrangements are established and include health and local authority partners.
• There is ambition for shared outcomes to allow place-led design of solutions and progress shared pathway ownership and development. Some arrangements have been made to refine care pathways.
• System leaders are collaborating with partners to improve quality and efficiency for more seamless services. Some progress has been made to establish integrated commissioning and co-location of services.
• Impressive information systems are in place to support delivery, but in early stages of demonstrating impact and understanding of how to use this information to ignite meaningful change. The ICS has invested in digital solutions such as Dorset Intelligence and Insight Service (DiiS).

Areas for development

• Further work is needed to improve oversight and learning from serious incidents at system level, including individual cases, trends and themes.
• System-wide improvements are needed to understand specific population needs, address access and outcomes for disadvantaged population groups, and articulate how specific groups are being prioritised to improve equity of access, experience and outcomes.
• Increased partnership working with local authorities is needed on wider determinants of health to connect local economy factors such as employment with health and social care.

Summary findings for quality statements under the Quality and safety theme

This theme includes these quality statements:

• Supporting people to live healthier lives
• Learning culture
• Safe and effective staffing
• Equity in access
• Equity in experience and outcomes
• Safeguarding

Quality statement: Supporting people to live healthier lives

Key messages

Dorset ICS organisations are starting to work collaboratively to support people to live healthier lives. There is some focus on health prevention and early help, and some initiatives to support people to make informed choices about healthier lifestyles for their physical and mental health. However, at the time of our assessment approximately 2% of the ICS budget was spent on prevention. System leaders recognised the need to increase this and articulated their aspirations to address wider determinants of health.

Collaboration to address the wider determinants of health

Health Index data show that people's health in Dorset is generally better than the England average. Dorset ranks seventh in England, with a Health Index average score of 106.7 in 2021. Dorset has consistently scored above the national target since 2015. This means overall population health in Dorset is better than the England average was in 2015. In Dorset, 10.4% of adults smoke, which is below the England average.

The NHS Dorset Joint Forward Plan 2023-2028 documents many examples of current and planned work to support people to live healthier lives. There is clear focus in the integrated community care model on helping people stay healthy by preventing problems before they start. There is intent to support and invest in voluntary and community organisations to help people do this. This includes a planned services review to make sure they are joined up, easy to access and closer to home, and connect people with support and physical activity opportunities through social prescribing. There are outcomes focused on children's health, inequality in access, outcomes and experience and social isolation.

The Dorset ICS Clinical Plan states the need for an active move to prevention and early intervention, so that people’s health and social care needs should be considered as a whole instead of multiple conditions; services must be designed to support and encourage people to manage their own conditions where possible, including focused investment to tackle inequalities in areas of deprivation and the greatest need.

Dorset VCSE leaders recognised the challenges faced by different communities, and gave examples of quality relationships that had developed to support residents during the Covid-19 pandemic which had created strong, vibrant and lasting networks.

Many VCSE representatives felt well-integrated and connected to other local voluntary organisations. There was a shared desire for a holistic approach to address local health issues and tackle health inequalities, greater VSCE representation in ICP decision making and more certainty around funding and commissioning, which they felt was a barrier to joined-up working around health and wellbeing.

Leaders recognized the need for increased focus on transformation to ensure that prevention, early help and health inequalities are addressed on equitable terms with operational priorities. However, there was recognition of national priority pressures and the need for cultural change across the ICS to shift the focus from protecting immediate needs to investment in prevention. Leaders identified a risk that delivery of the ICS’s 5 pillars is dependent on a positive shift in wider determinants of health for the population.

Quality statement: Learning culture

Key messages

There is a positive learning and safety culture developing in the system. However, leaders recognised there is no mechanism for sharing learning across the system and were working to address this. There are opportunities to use existing mechanisms and develop new systems to share learning and identify and embed good practice. Some staff gave a varied picture of how well-developed the learning culture is in the system.

The Dorset System Quality Group (SQG) is established and maturing. The group has good representation from system partners. A quality board is responsible for identifying, managing, mitigating and meaningfully learning from risks in local authorities. The collective strategic view on how to cascade information to teams and managing risks at a tactical level is still developing. The system identifies a collective management, and ownership of the risk is key to put learning into practice and co-production. However, the system does not yet have the structures to support this level of co-production, though it is working towards a proactive learning culture. Minutes for the last 2 meetings of the quality and safety committee did not reflect that sharing learning is embedded in this committee.

The system holds much data to support identification of risks and concerns. However, leaders acknowledged gaps in data about risks and concerns in the community and social care sector. Staff perceived a greater focus on learning from acute sector organisations because of these data gaps. ICS leaders were committed to addressing gaps in data to allow them to allocate resources to support all sectors.

The system is working towards a single process for addressing and responding to complaints in NHS trusts as a 2023/24 priority. The approach aims to improve how to respond to complaints from patients who receive care from multiple providers. The aim is for a single meaningful response from all providers that answers all concerns, as well as creating a system to share learning across organisations that are currently siloed. The timescale for completion was March 2024, but there was no action plan to implement an ICS-wide complaint response process.

There are system forums to share learning and ideas for specific provider groups and at place. At the monthly Registered manager group, staff from care homes found it helpful to share ideas and volunteer to be involved in different groups in their local area. There is also a well-established provider forum in place where staff told us they could raise concerns, felt listened to and received feedback. Key staff who attend the provider forum also attend ICB meetings and information is shared both ways through this group.

Designated safeguarding staff in NHS services regularly review patient safety incidents. However, they are no longer involved in outcome investigations, which limited opportunity to share learning across organisations and disciplines.

Staff representing homecare (domiciliary) services described useful learning cycles where funding is available to support improvement initiatives. However, lack of capacity or resources meant they cannot always progress initiatives, complete learning cycles or develop new unfunded ideas.

There are some processes for sharing learning and experience across health and social care leads. The Chair of the Integrated Neighbourhood Community Operational Group (INCOG) is integrated across the 2 local authorities with good links between health and social care leaders. Staff told us they share learning and recommendations into INCOG and learning from this group feeds into place-based pilots.

Executive leaders told us safety culture is set by the board; they are completing relevant training to support that positive learning culture. Key executive ICB members attend meetings and committees in other organisations to keep oversight of safety culture in the region, for example the Chief Nursing Officer attends local NHS trust quality committees to maintain oversight.

Quality statement: Safe and effective staffing

Key messages

Senior leaders across sectors and organisations identified workforce challenges as the biggest pressure and risk within the ICS, with a mismatch between capacity and demand for services. This meant the workforce was highly stretched and services across Dorset, particularly in social care, experienced operational and service delivery constraints. Medical staffing and social work staffing were concerns. There are system workforce plans to address shortages, improve retention, enhance education and training, and create supportive work environments. There were examples of integration and successful joint working, but it was too early to assess the impact of system-level workforce interventions.

There are organisational structures and governance mechanisms to address workforce issues. The ICB People and Culture Committee is attended by representatives across the system, with early signs of collective accountability and shared delivery. The system-wide workforce plan: 'Dorset Integrated Care System People Plan, Planning for the future 2023-2028', clearly articulates workforce challenges and the principles and objectives to address them. The system People Plan was developed collaboratively with input from all sectors in the ICS.

The joint workforce strategy acknowledges that the system needs to add value to Dorset communities by providing inclusive employment opportunities to address deprivation and local economic development.

In practice, we found many workforce initiatives were in scoping phase and more work is needed to establish a systemic, unified approach to HR and people policies across the system. Staff reported sovereignty barriers and protectionism were limiting workforce integration in some areas. Collaboration among stakeholders, including local authorities, providers, and voluntary organisations, is work in progress.

Retention is a key focus of the system workforce plan. Across all NHS providers in Dorset, data shows a higher rate of staff leavers than the national average of 8.2%, with Dorset County Hospital experiencing the highest rate at 9.6%. Retention efforts are co-ordinated across the system by the ICS People and Culture Steering Group and led by a central responsible senior leader. The ICB had secured funding to support cross-organisation retention plans. Several initiatives are working well to support and retain health and social care workers.

There is good recruitment support for internationally trained nurses, paramedics and ambulance technicians across bands and services. The ICB and ICS have also supported the establishment of a health and social care scholarship programme, which provides pathways and opportunities to individuals from less-advantaged local communities.

There is early development of a proactive, system-wide approach to workforce learning and development, including alignment of education and training programmes with health and social care system needs. System partners engage with local universities and employers to develop nursing apprenticeship schemes. There is a joint approach to leadership development and coaching. The GP Alliance, supported by the Primary Care Training Hub, provides primary care workforce training. Staff across sectors reported good formal supervision initiatives.

Quality statement: Equity in access

Key messages

There is early evidence the ICS is implementing changes to address inequalities in access to services. At all levels and from staff across Dorset, we heard commitment to the vision of investing in communities, equality and early prevention. Leaders were clear on the need to address inequalities in access and understand the challenges people face to access the services and support they need in a timely way. While intentions and ambition were clear, in practice we found the system’s rich data sets were not yet being used as an insight and intelligence tool to address inequalities in access.

Improved access to health and care and reduced inequalities in access

Leaders and staff told us their challenges in providing the population with equal access to services. These include:

• providing services in rural and remote areas of the county
• access to GP and dental services
• access to child and adolescent mental health services (CAMHS)
• acute and mental health bed capacity including challenges in discharge which affects bed capacity
• access to reablement and community services, including delays in access due to commissioning timescales.

Other challenges limiting people’s access to services included:

• isolated and deprived communities
• people living in poverty and the cost of living
• infrastructure barriers such as transport and housing.

The ICS has progressed several workstreams in 2023/24 to start to address equality of access and service delivery in CORE20PLUS5 priorities:

• elective care
• cancer care
• maternity services
• hypertension and respiratory disease
• antibiotic prescribing
• tobacco dependence
• access to children and young people's emotional wellbeing and mental health support services.

ICS plans to build on these areas to reduce inequalities and improve outcomes include developing an ICB forward plan, reviewing reporting and performance structures, and developing a health inequalities strategy.

The ICS Joint Forward Plan focuses on developing an integrated community care model to help people stay healthy and prevent problems before they start. As part of this, the ICS has committed to reviewing services to make sure they are easy to access when and where people need them. This is focused on:

• access to mental health integrated community care
• access to urgent care and treatment as close to people's homes as possible
• urgent treatment centres and other community units to allow quick and safe access to hospital
• people with a learning disability having access to the right care and support to live well
• plans to increase the number of children and young people accessing annual health checks to help find problems early and help them stay healthy.

The ICB added additional funded sessions so additional capacity was not blocked for routine dental care. The ICB plans to develop this work to identify other areas with insufficient access to target additional commissioned capacity for dental care. Some providers used DiiS to identify vulnerable populations or individuals who might benefit from additional support, but there was limited evidence of ICS partners utilising DiiS to inform commissioning activity or upscale activity in one area to pan-Dorset interventions. We were informed of challenges collating data from all areas of the system, which meant available data tended to be healthcare focused.

GP Patient Survey 2023 data show 8% of people who could not get a GP appointment went to A&E, better than the national average of 12% And 17% said the practice helped in another way, above the national average of 10%. The results overall show access to GP services in Dorset was better than the average experience in England, but with variations across neighbourhoods. In Blandford Primary Care Network, satisfaction of making an appointment was 42% compared to Mid-Dorset PCN where the experience was good at 83%. Although access to GPs in Dorset was better than the England average, access was not equal across the ICS.

Some VCSE groups have worked with the ICS on engagement strategies to address equity of access, including personalised communications and digital platforms. They acknowledged services need to reach out to, and be in, communities, not expect hard-to-reach communities to come to them. This work is ongoing.

Quality statement: Equity in experience and outcomes

Key messages

The ICS is starting to implement changes to address inequalities in experiences and outcomes for people using services. Everyone we spoke with demonstrated commitment to addressing health inequalities. Leaders are clear on the need to address inequalities in outcomes and experiences, and they understand the main challenges they face. The drive and ambition are evident, but we did not always hear a consistent view on how data would be used as an insight and intelligence tool to address these inequalities.

Monitoring and learning from peoples' experiences of care

The joint forward plan includes developing an integrated community care model, focused on helping people to stay healthy, preventing problems before they start and addressing inequalities in experience and outcomes. The ICS has committed to reviewing services to make sure they are easy to access when and where people need them.

System leaders and partners acknowledged that structures to address health inequalities are in their infancy. Dorset is data rich, but systems and processes to analyse data and use that analysis are not yet embedded in practice.

The system does not consistently tailor care and support to meet the needs of these population groups. Data show that 9% of people in Dorset who have a learning disability received an annual physical health check, below the England average of 11%, and 59% of people in Dorset with severe mental illness received an annual physical health check, in line with the England average. The target for cervical cancer screening is 75% nationally; in quarter 4 of 2022/23, 73% of eligible Dorset residents were screened. Although slightly below target, this was an improvement on the previous year. The ICS ranked 14th of 42 systems nationally.

Some staff told us about a disconnect between systems and strategies that are being developed, which affect people’s outcomes and experiences. For example, people have care home provision moved due to the fair cost of care initiative, which is distressing and not person-centred. Providers could not address the moves because they were linked to funding, and they were unable to offer care at a lower price.

Leaders and system partners articulated the importance of listening to people’s voices when developing plans to improve experience and outcomes. The ICS engaged in ‘100 voices’ to involve local people in service planning and delivery. Staff told us about plans to increase 100 voices to 10,000 voices using technology to expand the project, but plans were not yet developed to do this.

Quality statement: Safeguarding

Key messages

Dorset ICS system partners are collaborating well in a multi-agency approach to discharge their safeguarding responsibilities. There are strong networks and professional connections between staff and organisations, which enable formal and informal information sharing of local safeguarding intelligence as well as robust support and challenge. There is an open and transparent culture around reporting safeguarding and whistleblowing, and people feel able to speak up, share experiences and seek advice.

Although structures are in place, full integration and information sharing between NHS and other partners is in early stages and a true partnership approach is not fully established. There is also limited inclusion of the voice of children and young people in safeguarding processes and strategies.

Statutory safeguarding roles and formal governance systems are in place, including a Pan-Dorset System Quality Group and Adult and Children Safeguarding Boards, as well as place-based East and West Quality Groups. Chairs meet regularly to identify common issues and concerns. Actions from the board are cascaded to both places and there are mechanisms to share learning across both places.

There is a systemised approach to learning from safeguarding incidents such as Safeguarding Adults Reviews (SAR) and practice reviews, and a yearly commitment to train over 3,000 staff across Dorset providers and organisations in safeguarding. Safeguarding practitioners reported good supervision structures, including formal supervision for GPs.

Although structures were in place, full integration and information sharing between NHS and other partners was in early stages and a true partnership approach was not fully established. Senior leaders and safeguarding leads recognised this was an area for development.

The safeguarding adults multi-agency policy issued in February 2023 was developed with local authorities and other system partners, but still contained references to pre-ICB structures. There is also a multi-agency safeguarding procedure which had not been updated since the ICB had been established. There are risks that staff accessing this policy may not find the information they need in a timely way to support safeguarding responses.