Comment / Risky systems

The 2022 Health and Care Act puts in place a legal framework to enable services to work more closely together. That’s not just about the integrated care board (ICB) as a statutory body, but it’s also mandating and encouraging partnership arrangements, including the integrated care partnership and place-based collaboratives.

There are clear responsibilities to improve outcomes in population health, tackle health inequalities, enhance productivity and value for money, and help the NHS support broader social and economic development.

So what does that all mean for risk management? What has actually changed?

In some ways, nothing has changed. ICBs, as statutory bodies in the NHS, are expected to have appropriate risk management arrangements in place, including a board assurance framework (BAF). The ICB should have its own strategic objectives, and the BAF, as usual, should be reflecting the risks of achieving those objectives.

But in other ways, everything has changed – and this is for all NHS bodies, not just the ICB. That’s because all NHS bodies – along with local authorities, voluntary sector organisations and community groups – are an essential part of their local integrated care system (ICS).

In the same way that ICBs should have strategic objectives that reflect their aims, NHS providers should be updating their strategies to recognise their role in the ICS. For some providers, this will involve more than one ICS. This will then mean that they need to refresh their BAF to recognise the risks to them delivering their role in the system.

More challenging is the need to put in place system risk management arrangements across the system. We only need to think about some of the significant risks in the NHS at the moment – workforce shortages, long waiting lists, and pressures in unplanned care to name a few – where addressing the risks will require NHS organisations to work together more closely, alongside local authorities, the voluntary sector and communities themselves.

System risk management is going to be different to the risk management we are used to in individual NHS bodies. It is about bringing together partner organisations to share information and work through solutions together. It’s about collaboration and co-operation. There needs to be recognition that there are risks in individual organisations that will have an impact on other organisations – or indeed across the whole system. But the risk may be different, or impact differently.

For example, workforce shortages in the stroke unit at an acute provider, causing reductions in the number of patients that can be cared for, may well impact on patient outcomes, and on A&E waits for urgent care. But other organisations in the local health and care system will also be impacted. For ambulance trusts, the impact on A&E handovers could lead to worsening ambulance response times.

Worse outcomes for patients with strokes will have an impact across the health and social care system, including increased pressures on social care, community healthcare, primary care and the community equipment service. Ultimately a breach of targets for the system as a whole increases the risk of regulatory response.

So what is to be done? More than anything else, a change of culture is needed. It’s not just about managing the risk where it is now, it’s about reflecting on whether this will impact on partners in the health and care system, or on the ICB itself. Trust is needed, for different parts of the system to manage risks, and with trust comes accountability.

This isn’t about passing risks on for others to manage. The partners in an ICS remain statutory bodies and need to manage their own risks. But there may be risks that are best managed by another partner in the system.

For example, voluntary sector organisations, working with the local authority, may be most able to help support people experiencing homelessness, who are known to have high attendance at emergency departments – and the ICS is in a good place to co-ordinate this. Another possibility is that it may be more efficient and/or effective to manage the risk at a place or system level, for example, when working to improve a pathway.

On a practical level, ICBs need to put in place arrangements for consideration of risks across the system: a system risk group, with appropriate membership reflecting the make-up of the system, including the different partnerships and collaboratives. But the number of organisations involved in any ICS means that the membership won’t be representing every organisation. So alongside this, there needs to be appropriate communication and engagement with all relevant partners.

Risk management has generally been very transactional – but good system risk management needs thought and reflection, and an open mind when looking for solutions. There’s much to do, but the potential benefits for the health of our population are huge.