It is one of the greatest triumphs of our age that people are living longer. Many more of us are doing so with complex health and care needs, including multiple long-term conditions. To meet these needs, people rely on a range of health and care services, which are mostly public but also provided by non-statutory services (charities, social enterprises, community services and private providers), as well as dedicated informal support from families and carers. If these services and sources of support don’t join up, don’t share information, are not coordinated and fail to put the individual front and centre then this can not only result in a poor experience, but risks health problems escalating and an inefficient use of increasingly stretched resources.
Integrated care is about providing a more holistic, joined-up and coordinated experience for patients. Whilst there is not sufficient evidence that integrated care saves money or improves outcomes in the short term, there are other compelling reasons to believe it is worthwhile.
As health spending across the developed world looks set to consume an increasing share of GDP in the years ahead, integrated care provides a way of getting more value out of the resources we put in and a better experience for those who use services. There have been positive early signs from the new care models about the benefits more integrated health and care services can bring to patients.
Whilst there have long been efforts to join up services at local and national level, our inquiry explored the development of new integrated ways of planning local health and care services (sustainability and transformation partnerships and integrated care systems) and delivering care (integrated care partnerships and accountable care organisations), which have arisen out of the NHS Five Year Forward View.
We support the move away from a competitive landscape of autonomous providers towards more integrated, collaborative and placed-based care. However, understanding of these changes has been hampered by poor communication and a confusing acronym spaghetti of changing titles and terminology, poorly understood even by those working within the system. This has fuelled a climate of suspicion about the underlying purpose of the proposals and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services.
Sustainability and transformation partnerships (STPs) got off to a difficult start, with limited time to forge relationships, develop plans and make difficult decisions about changes to local health and care services. National media coverage of “secret plans”, “developed behind closed doors”, reflected the poor communication between local bodies and their communities. This, along with accusations that STPs were a smokescreen for cuts, tainted the STP brand.
The STP process has moved on since the original plans were published in December 2016, with the emphasis now firmly on the performance of the partnerships, rather than the delivery of their plans. The 44 partnerships are now at different stages in their journey towards further integration as integrated care systems (ICSs). Systemic funding and workforce pressures affect almost every area. Some areas have made considerable progress in light of these pressures, but those furthest behind are struggling with rising day-to-day pressures let alone transforming care.
ICSs are more autonomous systems in which local bodies take collective responsibility for the health and social care of their populations within a defined budget. A cohort of 10 ICSs, made up of the leading STPs, is currently paving the way for other systems. While these areas have made good progress in difficult circumstances, they are still nascent and fragile.
Integrated care partnerships (ICPs), alliances in which providers collaborate rather than compete, are becoming increasingly prevalent across the NHS, often building on the new care models programme and pre-existing collaborations between services. Two areas have expressed an interest in using an Accountable Care Contract to formalise their partnership into single organisations known as accountable care organisations (ACOs).
Public debate about the introduction of ACOs into the English NHS has been confused by concerns, mostly stemming from organisations with origins in the US which are different but also called ACOs. The main concern is the possibility that these new contracts might extend the scope of private sector involvement in the NHS. Based on our assessment of the evidence, this looks unlikely in practice but steps could and should be taken to reassure the public on this point.
There have also been misleading statements seeking to link ACOs, as proposed in England, with people having to pay for healthcare as in the US. There is no evidence that ACOs will lead to a dismantling of the fundamental principle that the NHS is free at the point of delivery.
The ACO model will entail a single organisation holding a 10–15 year contract for the health and care of a large population. Given the risks that would follow any collapse of a private organisation holding such a contract and the public’s preference for the principle of a public ownership model of the NHS, we recommend that ACOs, if introduced, should be NHS bodies and established in primary legislation.
Before this can happen, there are critical questions remaining, particularly whether using an ACO contract to merge services into a single organisation accelerates integration and improves outcomes for patients. Therefore we recommend that ACOs should be subject to careful evaluation.
The legal barriers and fragmentation that arose out the Health and Social Care Act 2012 will need to be addressed. A hung Parliament can make more comprehensive review and revision of legislation difficult, but all sides should work together to try to find agreement which allows for the joining up of services on which people depend.
Simon Stevens, head of the NHS and architect of the Forward View, has described these changes as the greatest move to integrated care of any western country. However, as yet, the scale of this ambition has not been matched by the time and resources required to deliver it. Countries that have made the move to more collaborative, integrated care have done so over 10–15 years and with dedicated upfront investment.
Transformation remains key to sustainability. We have seen and heard of examples of local areas which have made excellent strides forward in difficult circumstances. What is now required is the dedicated national financial and leadership support to enable the NHS to transform at pace. Too often plans are constrained by the upfront funding needed to make them effective.
The NHS is currently in survival mode, with NHS providers struggling to recruit, train and retain staff and balance their books, while maintaining standards in the face of relentlessly rising demand. A long-term funding settlement and effective workforce strategy are essential not only to alleviate immediate pressures on services, but to facilitate the transition to more integrated models of care.
The Government’s announcement of a long-term funding settlement is welcome. As the NHS turns 70, we recommend the Government and national leaders use this opportunity to improve the delivery of joined-up services. The Government and national leaders should:
a)Develop a national transformation strategy backed by secure long-term funding to support local areas to accelerate progress towards more collaborative, place-based and integrated care;
b)Commit to a dedicated, ring-fenced transformation fund;
c)Explain the case for change clearly and persuasively, including why it matters to join up services for the benefit of patients and the public.
d)Alongside these changes, the Government should facilitate national bodies to work with representatives from across the health and care community, who should lead in bringing forward legislative proposals to overcome the current fragmentation and legal barriers arising out of the Health and Social Care Act 2012. These proposals should be laid before the House in draft and presented to us for pre-legislative scrutiny.
Our report sets out several areas where we feel legislative change may need to be considered, including:
It must however be kept central to all the plans to create and develop new regional and local structures, partnerships and contracts that these are a means to achieve more coordinated, person-centred and holistic care for patients, particularly patients with long-term conditions.
Published: 11 June 2018