1.The term “integrated care” means nothing to most people. It is also poorly defined. National Voices, a coalition of charities focused on giving people greater control over their health and care, told us that a review of the evidence on integrated care found 170 definitions. Patients and the public, Don Redding, Director of Policy at National Voices, explained:
[ … ] want to feel that their care is co-ordinated, that the professionals and services they meet join up around them, that they are known where they go, that they do not have to explain themselves every single time, and, therefore, that their records are available and visible.
2.Patients and the public not only expect care to be integrated, but they believe this is already the case and are surprised when they encounter problems. Kate Duxbury, Research Director at Ipsos MORI, a polling company, told us:
If you say to a person that a hospital might not have access to their GP records and vice versa, they are very surprised about that and will assume it is already happening.
3.The public are often unaware of the divides between health and social care services, whether that be primary and acute care or NHS and social care. For example, a patient receiving homecare from their local authority is just as likely to think that the service is provided by the NHS.
4.A shared commitment signed by the Department of Health, its arms-length bodies, the Association of Directors of Adult Social Services and the Local Government Association included the following definition which expresses the essence of integrated care from a patient’s point of view:
I can plan my care, with people who understand me and my carers, allow me control and bring together services to help me achieve the outcomes that are important to me.
5.As Simon Stevens, Chief Executive of NHS England, explained, integration occurs along a spectrum, across which services can be more or less integrated. Integration is not necessarily as important for every patient, but is of particular significance to people living with chronic conditions and complex health and care needs.
6.Patients living with complex health and care needs and long-term conditions, together with their families and carers, may draw on a range of public and non-statutory services (charities, social enterprises, community services and private providers) , including digital services. This personalised network may be opaque to health and care services and professionals within it. This has important implications for how policymakers and local services think about integration. Dr Charlotte Augst from The Richmond Group of Charities, a collaboration of 14 leading health and care charities, told us how integration is often thought about from the perspective of the services involved, rather than patients:
Often, I think it is only the patient and their carer who understand who is on the team. Therefore, if you do not start by asking that question, you do not understand which pharmacy, which GP, which hospital consultant and which charity are on the team and therefore what we are co-ordinating. From the patient perspective—the care perspective—it is really important to understand what it is we are trying to co-ordinate so that you are rolling it out from that end rather than from the integration end, which always starts with structures.
7.From a patient’s perspective, integrated care is about how patients experience the health and care services they use. Healthcare has historically been delivered in a paternalistic, siloed fashion. However, patients’ interactions with healthcare services account for only a fraction of their lives. The ability of patients to manage chronic conditions themselves is therefore critical to their health and wellbeing. Adopting a more person-centred approach, in which patients are supported to manage their conditions more independently, requires a radical shift in how health and care is delivered. This would entail, as Don Redding described, services in which:
We (health and care professionals) find out what their (patients) priorities and goals are, we work to support those, and we judge outcomes by the extent to which people can achieve good outcomes.
8.Integrated health and social care has been a longstanding ambition of health policy pursued by successive governments over decades. There are three levels at which care can be integrated: patient level, service level and organisational level. The National Audit Office provide the following examples of each:
a)Integration at a patient level may consist of joint assessments of a patient’s needs by multiple professionals and services.
b)An example of integration at a service level is when multiple services are brought together in one place for patients with a particular condition (e.g. diabetes).
c)Examples of integration at an organisational level include jointly commissioning services or pooling budgets.
9.The remainder of this report focuses on organisational and service level integration, particularly the emerging ways in which local health and care services are being planned (sustainability and transformation partnerships and integrated care systems) and delivered (integrated care partnerships and accountable care organisations).
10.For people relying on health and social care, ‘integration’ is about joining up the services they use and putting them as individuals at the centre, sharing information, working collaboratively, supporting them to manage their own health and focusing on what matters to them: their priorities, goals and aspirations.
11.It is absolutely essential not to lose sight of the patient and their families in any debate about NHS and care reform. Organisational and structural changes are merely a means to an end: the litmus test to determine whether these reforms succeed will depend on how effectively these new structures and organisations deliver better integrated care at the patient level.
12.The Department of Health and Social Care, NHS England and NHS Improvement should clearly define the outcomes the current moves towards integrated care are seeking to achieve for patients, from the patient’s perspective, and the criteria they will use to measure whether those objectives have been achieved.
13.Our predecessors launched an inquiry on Sustainability and Transformation Partnerships, which was cancelled when Parliament dissolved for the General Election. We decided to resume this inquiry and launched our call for evidence in November 2017.
14.Before starting our oral evidence, we decided to focus our attention on the recent debates about the new forms of integrated care emerging in the NHS (particularly Integrated Care Systems, Integrated Care Partnerships and Accountable Care Organisations). Along with STPs, we have sought during this inquiry to judge the desirability of ICSs, ICPs and ACOs in policy terms, seeking to assess whether, and to what extent, they will improve health and care services for patients.
15.On Tuesday 20 February 2018 we visited South Yorkshire and Bassetlaw STP, one of the leading integrated care systems, at which we held a focus group with national and local leaders from the NHS and local government (see Annex 1 for more information about the visit).
16.We held three oral evidence sessions, during which we heard from stakeholders across the health and care community, including campaign groups, professional bodies and trade unions, representatives of small, medium and large charities, pollsters, think-tanks and academics, representatives of NHS providers, commissioners, and local government, along with ministers and senior officials.
17.We are very grateful to all those who gave evidence to us, both written and oral. We are also grateful to our specialist advisers, Professor Chris Ham and Dr Anna Charles of the King’s Fund, and Professor Pauline Allen of London School of Hygiene and Tropical Medicine, for their advice and guidance throughout our inquiry.
18.During our inquiry accountable care organisations have been the subject of two judicial reviews. The first, by 999 Call for the NHS, contends that the ACO contract breaches sections 115 and 116 of the Health and Social Care Act 2012, which includes provisions for the price a commissioner pays for NHS services and the regulations around the national tariff.
19.The second, by a group known as JR4NHS, disputes whether the consultation process involving the draft ACO contract was legal. JR4NHS argue that the decision to introduce regulations in February 2018 before the ACO contract itself had been consulted on effectively prejudged the lawfulness of the future contract.
20.We have not during this inquiry sought to make any judgement about the legality of ACOs, or any of the other emerging forms of integrated care. These matters are for the courts to decide. Instead, as mentioned earlier, we have sought to judge the suitability of these mechanisms in policy terms: will they help local services to integrate care, maximise the use of resources and, mostly importantly, improve patient outcomes and experience.
4 Ipsos MORI(0104) p4
9 National Audit Office, , HC 1011 Session 2016–17 8 February 2017, page5
10 Professor Pauline Allen declared the following interests: I hold a series of research grants from the Policy Research Programme of the National Institute for Health Research. The following research concerns issues of relevance to the inquiry: 1)Diverse Healthcare Providers: Behaviour in response to commissioners, patients and innovations; Professor Rod Sheaff, Plymouth University is the Principal Investigator and I am a co-investigator.
2) Understanding the new commissioning system in England: contexts, mechanisms and outcomes; Professor Katherine Checkland, Manchester University is the Principal Investigator and I am a co-investigator. 3). National Policy Research Unit in Commissioning and System Management in the NHS; Professor Stephen Peckham of Kent University is director and I am co director with Professor Kath Checkland.
Professor Chris Ham declared the following interests: The King’s Fund is working to support accountable care systems in England and some of the funding for this work has been provided by NHS England. Our work on STPs was funded entirely by The King’s Fund.
Anna Charles declared the following interests: The King’s Fund is providing support to accountable care systems in England. This work has been partly funded by NHS England. Our work on STPs was funded by The King’s Fund.
11 , Briefing paper: Number CBP 8190, 5 March 2018, page 12
12 , Briefing paper: Number CBP 8190, 5 March 2018, page 12–13
Published: 11 June 2018