21.Integrated care has been a longstanding ambition pursued by successive governments. As far back as 1972, a National Health Service Reorganisation white paper described the need for more coordinated care outside hospitals:
There is a need for far more … services that support people outside hospital. Often what there is could achieve more if it were better co-ordinated with other services in and out of hospital.’
22.Progress towards achieving integrated health and social care across England has been slow. Personal health budgets, integrated care pilots, integrated care pioneers, the Better Care Fund, joint strategic needs assessments and joint health and wellbeing strategies, as well as legal duties on NHS clinical commissioning groups and health and wellbeing boards to promote integration, have all been intended to bring about more integrated care.
23.The House of Lords report on the Long-term Sustainability of the NHS and Adult Social Care, published in April 2017 stated:
system-wide integrated services were still very far from being a reality. Integration policy has been discussed for decades but it was clear from the evidence that there was a degree of frustration at the lack of progress on the integration of either funding or service delivery.
24.This point was echoed by the NAO, who concluded that 20 years of initiatives to join up health and care has not resulted in integrated services across the system. Instead, “progress with integration of health and social care has, to date, been slower and less successful than envisaged and has not delivered all of the expected benefits for patients, the NHS or local authorities.”
25.Integrated care remains the Government’s ambition. The 2015 Spending Review set a target for health and care to be integrated across England by 2020. Local areas were required as part of the Spending Review to develop plans by April 2017, setting out how they plan to achieve this objective. This work was then rolled into sustainability and transformation plans.
26.The Government’s mandate to NHS England in 2015/16 also set a target for 20% of the country to be covered by new care models by the end of 2017/18, rising to 50% by 2020. This objective has been rolled into successive versions of the mandate.
27.Integrated care has been pursued with the triple aim of improving outcomes, improving patient experience and delivering financial savings. However, as the NAO has highlighted, there is currently insufficient evidence to demonstrate that integrated care leads to better outcomes, financial savings or reduced hospital activity. The observable benefits of integration for patient experience at an individual level have not yet translated into robust evidence that integrated care leads to better outcomes or saves money. In addition, rather than saving money, more integrated care may also identify currently unmet needs, thereby adding costs in the short term.
28.The NAO concluded that slow progress over the last 20 years casts doubt on the Government’s plan to deliver integrated health and social care services across England by 2020. The NAO made the following observations of the performance of government departments and national bodies in delivering integrated care:
a)The bodies are still developing their understanding of how to measure progress on integrating care.
b)The oversight and governance of initiatives to deliver integrated care is poor.
c)The main barriers to integrated care are not being systematically addressed.
29.The practicalities of integrating services are complex. Simon Stevens described how structural divides imposed when the NHS was originally founded no longer make sense today: for example, the distinction between an NHS that is free at the point of use and a means-tested social care system, or the contractual separation of general practice from other NHS services.
30.Integration depends on building new ways of working and developing relationships between professionals in different services. These health and care services often have different cultural practices, legal accountabilities, payment systems and terms and conditions for staff, all of which create obstacles to integrated care.
31.Nigel Edwards, Chief Executive of the Nuffield Trust, emphasised the significant optimism bias inherent in the ambition of the Department and national bodies, which does not adequately appreciate the scale and nature of the changes required. As Mr Edwards explained:
These models take a long time to develop. They are based largely on changing the way people practise medicine and how complex organisations interrelate, and indeed how individual relationships between different clinicians and organisations change and morph over time. There is very little way of accelerating that process; it has to be learned and developed.
32.Alongside efforts to integrate health and social care over the last 20 years, policymakers have also sought to introduce greater choice and competition within health and care system in England. The NHS Health Service and Community Act 1990 created an internal NHS market, introducing a spilt between the provision and commissioning of healthcare with the creation of self-governing trusts and GP fund-holders.
33.The NHS internal market continued throughout the 1990s, but accelerated at the turn of the century with a series of reforms, including the introduction of payment by results (PbR) in 2002, the establishment of foundation trusts in 2003 and the introduction of primary care trusts. This period also saw an extended role for the private sector in the NHS, under successive governments.
34.The Health and Social Care Act 2012 was the culmination of the shift towards choice and competition within the NHS. The Act saw the creation of NHS clinical commissioning groups responsible for commissioning services for their local populations. This was supported by reforms designed to support a diverse and competitive landscape of public and non-statutory provision, with an extended role for Monitor as the economic regulator.
35.Rt. Hon Andrew Lansley MP, then Secretary of State for Health, told our predecessor Committee in 2011:
What we are doing, through amendments to the legislation, is to make it absolutely clear that integration around the needs of patients trumps other issues, including the application of competition rules.
However, despite that reassurance, reforms to extend the NHS internal market, including the role of competition, have impeded rather than supported services to integrate. The NAO concluded that:
shifts in policy emphasis and reorganisations which promote competition within the NHS, such as the move from primary care trusts to clinical commissioning groups in 2013 and the Health and Social Care Act 2012, have complicated the path to integration.
36.Mr Stevens described how at the heart of the Forward View is the aim to not only work around, at least in the short-term, aspects of the Health and Social Care Act that promote competition over collaboration, but also to lower unhelpful boundaries between services that were imposed from the creation of the NHS.
37.Competition, and the fragmented provision that arises as a consequence, erects barriers to integrated care. However, patient choice is where these two competing agendas converge. Our view is that a diverse local health and care economy, with a mix of mostly public, but also non-statutory services (private providers, social enterprises, charities, and community and voluntary services), can be arranged so as to enable rather than detract from integrated care. From a patient’s perspective, what matters is that these providers, whether public or non-statutory, create coherent and comprehensive services, share information, work together and put patients’ needs, priorities and goals at the centre. From the NHS’s perspective, non-statutory services must enhance and not undermine the ability of the NHS to serve local populations.
38.Patients’ ability to choose and access a range of different services and sources of support, from which they may find therapeutic benefit, should be preserved. Public and non-statutory services both have a role to play in a diverse local health and care economy, which favours collaboration and quality over competition.
39.Not only do non-statutory services provide support when statutory services are stretched, but they can in some circumstances be more adept at meeting unmet demands in ways that statutory services may struggle to do. Competition can also be a useful tool but this should be on quality, not a race to the bottom on price. New entrants to the market can provide an incentive for incumbent providers to improve.
40.Having a “free choice system playing in”, as Julie Wood, Chief Executive of the representative body NHS Clinical Commissioners, described, does create a challenge for NHS bodies seeking to maximise the value of the NHS pound, as they have to pay for NHS staff and then again for another intervention. We appreciate this concern. However, one of the warnings against removing choice and competition is that “there is a danger of creating airless rooms in which you simply have one provider who is there for a huge amount of time.”
41.More joined-up, coordinated and person-centred care can provide a better experience for patients, particularly those with multiple long-term conditions. However, progress to achieving these benefits has been slow. There is no hard evidence that integrated care, at least in the short term, saves money, since it may help to identify unmet need, although there is emerging evidence from new care models that it may help to reduce the relentless increase in long-term demand for hospital services.
42.More integrated care will improve patients’ experience of health and care services, particularly for those with long-term conditions. However, the process of integrating care can be complex and time consuming. It is important not to over-extrapolate the benefits or the time and resources required to transition towards more integrated care.
43.The Government should confirm whether it is able to meet the current target to achieve integrated health and care across the country by 2020, as well as plans for 50% of the country to be covered by new care models. These targets should be supplemented by more detailed commitments about the level of integrated care patients will experience as a result.
44.We support the move towards integrated, collaborative, place-based care. To help deliver more integrated care for patients we advocate the cultivation of diverse local health and economies, comprised of mostly public, but also some non-statutory provision, in which the organising principle is centred on collaboration and quality rather than financial competition. We consider that this diversity is important for protecting patient choice and with proper oversight and collaborative working may facilitate, rather than impede, joined-up, patient-centred and co-ordinated care.
13 Department for Health and Social Security (1972) National Health Service Reorganisation: England. HMSO:London
14 House of Lords Select Committee on Long-term Sustainability of the NHS, Long-term Sustainability of the NHS and Adult Social Care, April 2017, para 90.
15 National Audit Office, , HC 1011 Session 2016–17 8 February 2017, page 12
16 National Audit Office, , HC 1011 Session 2016–17 8 February 2017, page 6
17 Department of Health, , March 2017
18 National Audit Office, , HC 1011 Session 2016–17 8 February 2017, page 7
20 The Nuffield Trust, , March 2017, page 5
21 The Nuffield Trust, , March 2017, pages 9–10
22 Q325 [Simon Stevens]
24 The House of Commons Health Committee, , 19 July 2016 HC 139, para 116, footnote 146
25 National Audit Office, , HC 1011 Session 2016–17 8 February 2017, page 7
27 Q209 [Julie Wood]
28 Q209 [Niall Dickson]
Published: 11 June 2018