New roles in integrated healthcare: what can we learn from the rest of the world?

In 2013, the King’s Fund published a case study on integrated care in Canterbury in New Zealand². In it they suggest:

“A significant and sustained emphasis has been made in equipping the workforce first with the insight that it is employees and contractors who can change the way care is delivered and then giving them access to the tools to help achieve that. It is an illustration of how change can be brought about primarily ‘from within’ by empowering clinicians and others who are prepared to take responsibility for changing the way things work, instead of seeking to drive change through external stimuli such as top-down performance management and market incentives.”

They talk about the commitment to long-term training and development in Canterbury and the fact that they have drawn on the intrinsic motivation of staff to provide high-quality care to create new integrated care pathways. It was also the case that the need for change emerged partly because the alternative - which included building new hospitals and doubling the size of the workforce - was simply unaffordable.

Elsewhere, KPMG discusses the challenges it faced while supporting the development of New York State’s medical system, which is described as being ‘not unlike the NHS’ because it needed to meet the triple aims of better health, better care and lower costs³. KPMG reports that workforce strategy was one of the key enablers of the five pillars of transformation including: improving access to care; integrating care to address patients’ needs; making the cost and quality of care transparent; paying for healthcare value not volume; and promoting population health. It describes a whole workforce transformation based on the introduction of new roles and training schemes.

Like in the NHS, the starting point for transformation in New York featured workforce shortages, particularly in primary care. The state also suffered from the fact that the healthcare workforce was not as diverse as the populations it served. Regulatory barriers prevented cross-system, team-based working, with many practitioners not working to the full scope of their professional competence. They also had incomplete data on the state of the healthcare workforce in terms of workforce gaps, education needs, roles and responsibilities.   Contextually, therefore, there were some distinct similarities with the NHS. KPMG writes:

“Emerging patient care delivery models will demand new strategies to better prepare the health workforce to deliver these models of care. Traditional silos will need to be broken down, staff will need to work more collaboratively in multi-disciplinary teams, and better information on the workforce will be required.”

Training started by preparing the workforce to think differently and across systems. This awareness helped existing staff to understand and work with others in the system and provided the foundation for team-based working and the design of team-based solutions.

Re-training the existing workforce in line with changing roles and expanding the scope of practice for existing professionals was instrumental in breaking down traditional silos. Creating new roles meant opening up opportunities to a new target audience, which allowed for a more inclusive approach to healthcare recruitment. The development of more community-based support roles also expanded capacity for care co-ordination The system worked with regional training providers to stand up new courses and programmes to deliver the workforce of the future.

This thinking is mirrored in a number of other studies.  A research paper in The Journal of Social Science and Medicine (2021)⁴ suggests that:

• at the macro level, systems need to understand workforce demography and undertake workforce planning
• at the meso level, continuing professional development for existing practitioners should focus on skills for integrated care, new professional roles should be created and support should be provided for informal care-givers
• at the micro level, professionals should learn how to work in multi-disciplinary teams with a named co-ordinator

What does this tell us about what we should now? There are some obvious conclusions, and work on most of these is already underway in many areas:

Break down barriers to enable people to work across ‘silos’

Passporting is obviously relevant here but so too is the removal of cultural barriers related to different ways of working and different ways of thinking; getting people to work together across settings is probably more relevant than sharing workers on a system-wide basis

Build system awareness and understanding

Cultural and operational barriers often manifest due to a lack of awareness and understanding. Awareness training – along with increased opportunity for staff to work together across the system and learn from others about the challenges in other areas - helps to create appropriate patient-centred pathways

Listen to the care-givers

Motivated by their passion to care for others, those closest to patients and delivering the service are probably the best placed to develop new solutions. They should be given a voice and given the tools and frameworks to co-design and develop new ways of working

Create new roles

We already know that we will need more care co-ordinators, more people supporting patients out in the community and a whole host of roles to support the ‘prevention’ agenda. Models around the world reveal new roles covering:

• health information exchange: managing the electronic sharing of patient data
• population health management: analysing health data and trends and developing strategies to improve outcomes and prevent illness within the population served
• behavioural health navigation: helping patients to navigate complex health systems including mental health, connecting them with appropriate resources and co-ordinating their care with other healthcare providers
• transitional care co-ordination: supporting the transition of patients between different care settings (for example, hospital and home) and ensuring they receive the necessary support and follow-up care to prevent complications and re-admissions
• telehealth co-ordination: facilitating virtual consultations and co-ordinating remote monitoring
• health coaching: working to empower patients to take an active role in the management of their own health by providing education, supporting self-management strategies and helping people to achieve their health goals
• community health: providing culturally sensitive health education to under-served communities
• community pharmacy: helping patients to manage their medication and providing medication advice

Upskill existing workers

Preparing people for cross-silo working, helping them to develop skills to extend their role and work effectively and efficiently with digital systems.

Training a new generation

As a major flexible workforce provider, NHS Professionals is fully aware of these challenges and opportunities and much of our work is now geared towards supporting individuals and systems to thrive within the integration context. Learning from the rest of the world, we know that the ability to recruit and train a new generation of workers lies at the heart of integrated healthcare transformation.

Our Academy, for example, is developing appropriate training and support for flexible staff to ensure they remain ‘work ready’ in the new world of integrated care. In addition we are actively exploring how we can use flexible deployment vehicles (such as shared banks and our ‘National Bank’) to mobilise staff more effectively on a system-wide basis.

This also means developing a new cadre of worker able to work in all parts of the healthcare system, and using the knowledge they gain in doing so to lead the change agenda. We have the capacity to use these resources to develop training pathways for new roles and system-wide opportunities. Ultimately, we are responding to the recommendations in the Long-Term Workforce Plan. These suggest the workforce needs to be upskilled and cross-skilled in a way that supports NHS reform, and we are developing flexible workers accordingly. In this way we see our flexible workers playing a key strategic role in healthcare integration in the future.

^[1] Goodwin N. ‘Understanding Integrated Care’. International Journal of Integrated Care. 2016; 16(4): 6 DOI: 10.5334/ijic.2530. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

^[2] Timmins N, Ham C, ‘The quest for integrated health and social care: A case study in Canterbury, New Zealand’, The King’s Fund, 2013, pp 45-46.

^[3] New Care Models: International learning from New York State’s Medicaid reforms’, KPMG, July 2016, p20.

^[4] Looman W, Struckmann V,  Köppen J,  Baltaxe E,  Rutten-van Mölken, M,  ‘Drivers of successful implementation of integrated care for multi-morbidity: Mechanisms identified in 17 case studies from 8 European countries’, Journal of Social Science and Medicine, Vol. 277, May 2021.