Integrated care: organisations, partnerships and systems Contents

6Concerns about the direction of travel

157.There are five key concerns arising out of the NHS Five Year Forward View process. We describe, and respond to, each in this chapter. Some of these concerns reflect genuine obstacles to transformation and risks to the sustainability and cohesion of the health and care system. Others, however, such as assertions that the NHS is being ‘Americanised’ in a way that will lead to people having to pay for care, are creating a climate that risks blocking the joining up of services in the interests of patients.

158.We know from polling that the British public are worried about the future of the national health service.133 The way national bodies communicate has often exacerbated public concerns. For example, the language of the NHS, and the wider health and social care system, is full of unhelpful jargon (See Chapter 7).

159.The positive underlying intention of the NHS Five Year Forward View process is clouded by unhelpful acronym spaghetti. Jargon, we heard from Dr Charlotte Augst from the Richmond Group, is not only ineffective, it raises suspicion. The public do not understand these acronyms, which leads some to think there is a story they are not being told.134 Niall Dickson, Chief Executive of the NHS Confederation, made this point:

I suspect that Mr and Mrs Smith walking down the road probably do not know what STP stands for and do not understand a lot of this process. That is part of the problem, but the way it was launched and people’s genuine fears about what might happen have become attached to both the letters and the process, and we have to move on from that.135

160.The Government and national bodies must take responsibility for finding effective solutions to address the key funding and workforce pressures on the system. However, we frequently see and receive messages from campaign groups that are inaccurate, misleading and play on the public’s genuine concerns. These messages make it harder for local organisations to make progress. For example, as Niall Dickson described, negative labels attached to the STP brand have tainted the process.136

Top-down reorganisation of the NHS without public consultation and parliamentary scrutiny

161.Current changes to regional structures and local organisations, such as STPs, ICSs and ACOs, focus on integration at the organisational level. We have heard concerns that these reforms constitute another top-down reorganisation of the NHS, which is taking place without adequate public consultation or parliamentary scrutiny. This focus, it is argued, is a distraction from the task for integrating care for patients.137

162.Dr Graham Winyard, a former National Medical Director for the NHS in England, argued that the NHS has had 35 years of changes to the organisational superstructure. He told us that integrated care depends on relationships between professionals; the NHS superstructure can either impede or support inter-professional working.138 Dr Tony O’Sullivan from Keep our NHS Public echoed this view, saying:

It is top-down. The integration is integration of management systems, of financial purses and of organisations, and, to me, it is at the expense of the integration of true delivery of co-ordinated care that has been going on and did not need Simon Stevens or Jeremy Hunt to tell us to do it.139

163.The current suite of NHS reforms is seeking to remove barriers and blur obstructive boundaries between services (see Chapter 2). Examples include the opportunity to use an ACO contract to bring primary care, community services and social care into one organisation to allow more streamlined decision making. Integrated care systems for example, can align incentives (e.g. through the use of capitated budgets) for better preventative care, thereby moving away from tariff arrangements which drive hospital activity.

164.Removing barriers at an organisational level is one part of improving integrated care. However, these changes alone are not the solution. Integrating care at the frontline is also about the workforce challenge, dependent primarily on building relationships between professionals. Simply removing external obstacles will not be sufficient to address the wider cultural and relational challenges of integrating care. So far scarce attention has been paid to the role of national bodies in building and supporting the intrinsic capability and capacity of frontline staff to improve, integrate and transform care.

Inadequate response to system pressures

165.We heard concerns from Keep Our NHS Public (KONP), a national campaigning body, that integrated care is often asserted as a solution to the NHS’s problems. KONP argue that the narrative described in the NHS Five Year Forward View is an inadequate response to fundamental problems facing the NHS: staff shortages, funding levels and the separation of health and social care.140

166.There is widespread recognition that the moves to more integrated care are not a solution to systemic funding and workforce pressures facing health and social care services. These pressures represent significant barriers to the transformation of care, which if not adequately addressed, will compromise the NHS’s ability to maintain the quality of existing services, let alone enable staff to find the time to transform care. The extent and implications of these barriers are described in more detail in Chapter 7.

167.Sustainability and transformation partnerships, and the more advanced integrated care systems, provide a mechanism to move away from the autonomous competitive arrangements imposed by the Health and Social Care Act 2012, towards a collaborative, placed-based approach to care. These mechanisms are no substitute for effective solutions to funding and workforce pressures, but if well designed and implemented they can represent a better way to manage resources in the short-term, including using the skills of staff more effectively on behalf of patients.

Smokescreen for cuts

168.A specific requirement of the sustainability and transformation plans was to quantify the funding gap in each footprint, along with proposals to fill this gap. Difficult decisions facing local areas, and the short timeframe in which they had to develop their plans, led to STPs being labelled as a “smokescreen for cuts”.141

169.Helga Pile, Deputy Head of Health at UNISON, argued that the STP initiative is “being seen as a means of delivering cuts to spending, and that means that many of the aims that they have that would benefit patients are not being identified and recognised.”142 This point was echoed by Dr Chaand Nagpaul from the British Medical Association. Based on information obtained from the BMA’s regional offices, Dr Nagpaul pointed to reports from BMA members that the boards of STPs are “talking about how we make cuts”, rather than how to transform care.143

170.STPs originated in a time of financial constraint. These challenging circumstances meant partnerships were faced with difficult decisions from their inception. As Ian Williamson from Manchester Health and Care Commissioning explained:

You asked about cost-cutting. Frankly, we all live in a world where we have budgets that we must stay within, and it is our role to do so. I do not think there is a part of the NHS in the country that is not struggling to manage a set of very competing pressures.144

171.The main criticism that STPs are a smokescreen for cuts conflates the principle of bringing local leaders together to plan services and manage finite resources with the difficult decisions the current funding envelope imposes on these partnerships. Conflation of these two separate points has unfortunately contributed to the negative, and tainted, perception of STPs.145


172.Fears that the NHS is being privatised have been projected onto various changes in health policy since 1990. The World Health Organisation in 1995 defined privatisation as “a process in which non-government actors become increasingly involved in the financing and/or provision of healthcare services.”146 Privatisation encompasses the transfer of government or state assets, organisations and operations to the non-government actors.147

173.Private sector involvement in the NHS is very different to the private insurance based systems found in other countries (e.g. the US). Private companies have played a role in the NHS throughout its 70-year history; most GP practices are profit-making independent contractors to the NHS and community pharmacies are private businesses for example.148

174.The vast majority of the British public support the founding principles of the national health service.149 No mainstream political party supports shifting the NHS from a tax-funded system to a private insurance model. When given a choice, most people would prefer their NHS-funded care to be provided by the NHS, rather than non-statutory providers (up from 39% in 2015 to 55% in 2017). However, 30% of the population have no preference whether their NHS-funded care is delivered by the public, private or voluntary sector.150

175.There has been an expansion in the role of the private sector since the early 2000s: for example, the use of private sector investment to fund new hospitals (e.g. private finance initiative) and independent treatment centres to reduce waiting times for elective care. More recently, there has been an increase in non-NHS providers of NHS-funded care, with the most significant increase being in community health services. Community health service contracts have gone to a range of providers including charities, social enterprises and community interest companies as well as private companies.151

176.Keep Our NHS Public have argued that the underlying motive of national bodies is to transfer large parts of local health and care provision into the private sector through the use of an accountable care contract. Dr Tony O’Sullivan, Co-Chair of Keep Our NHS Public, told us that:

these things have been put in place because of the top-down plan to go on a journey, which includes, I am afraid—we have not really discussed this—the assumption of a growing degree of privatisation, to an end form of ACOs that are independent bodies outside the NHS, so you have fragmented the NHS.152

177.We heard repeatedly, however, from a series of both local and national leaders, that the direction of travel is more likely to reduce private sector involvement rather than increase it. This is explained in more detail in Chapter 5. However, fears about privatisation have been projected onto the NHS Five Year Forward View process, making the challenge of integrating care more difficult. Niall Dickson from the NHS Confederation argued:

A lot of the comment is misinformed. The idea that this is a secret plot in Jeremy Hunt’s desk to privatise the NHS is palpable nonsense. Everybody involved in the process knows that that privatisation argument is nonsense, but it has certainly tainted the (STP) brand.153

Paying for healthcare

178.Doctors for the NHS expressed a concern that blurring boundaries between health and social care could result in charges being introduced for services currently classified as healthcare. For example, Dr Colin Hutchinson, Chair of Doctors for the NHS, explained:

At my local authority health and wellbeing board, the medical side of the collaborative agrees that there are situations where the definition of what is classified as healthcare and what is classified as social care could become very important, such as the use of intermediate care beds, including the care B&B type of model that has been suggested. Are those health or are they social care? The use of rehabilitation services, particularly if they are delivered in patients’ homes, raises the possibility of hotel charges for non-direct medical care for patients staying in hospital. If you are dissolving those boundaries, it does need to be defined, otherwise people will receive unexpected bills.154

179.Simon Stevens, Chief Executive of NHS England, provided assurance that it is crucial that NHS care remains free and based on patients’ need rather than ability to pay. He said that this is “a founding and enduring principle in the NHS, and nothing that is proposed will change it.”155

180.With pooled budgets and alignment of incentives to reduce hospital stays, it is likely that the blurring of boundaries could advantage rather than disadvantage patients by seeing more personal care directly funded by the NHS for limited periods after discharge. For example, the Discharge to Assess model in Sheffield entails patients being discharged when they are medically fit and having their support needs assessed at home by an immediate care or social care team. The model has reduced length of stay and helps to ensure patients receive the right support at the right time.156

Conclusions and recommendations

181.STPs, ICSs and ICPs currently have to work within the constraints of existing legislation and manage rising pressures with limited resources. This context limits progress towards integrating care for patients.

182.Some campaigns against privatisation confuse issues around integration. Concerns expressed about the ‘Americanisation’ of the NHS are misleading. This has not been helped by poor communication of the STP process and the language of accountable care, neither of which have been adequately or meaningfully co-designed or consulted on with the public or their local representatives.

183.We recommend that the efforts to engage and communicate with the public on integrated care which we refer to above should tackle head-on the concerns about privatisation, including a clear explanation to the public that moves towards integrated care will not result in them paying for services.

184.We recommend that national bodies take proactive steps to dispel misleading assertions about the privatisation and Americanisation of NHS. The Department should publish an annual assessment of the extent of private sector in the NHS, including the value, number and percentage of contracts awarded to NHS, private providers, charities, social enterprises and community interest companies. This should include an analysis of historic trends in the extent of private sector involvement over a 5–10-year period.

133 Ipsos MORI (STP0104)

134 Q155 Dr Augst

135 Q206 Niall Dickson

136 Q206 Niall Dickson

137 Q18 Dr Graham Winyard, Q8 Dr Tony O’Sullivan

138 Q18 Dr Graham Winyard

139 Q8 Dr Tony O’Sullivan

140 Keep Our NHS Public (STP0093)

141 Keep Our NHS Public (STP0093) UNISON (STP0057) Unite the Union (STP0070)

142 Q84 Helga Pile

143 Q86 Dr Nagpaul.

144 Q160 Ian Williamson

145 Q206 Niall Dickson,NHS Clinical Commissioners (STP0064)

146 Full Fact, Ask Full Fact: Does the World Health Organisation think the UK no longer has an NHS? 21 March 2016

147 OECD, Glossary of statistical terms: Privatisation, accessed on 2 June 2018

148 The King’s Fund, Is the NHS being privatised? 22 August 2017

149 Ipsos MORI (STP0104)

150 Ipsos MORI (STP0104)

151 The Health Foundation, Briefing: Provision of community care: who, what, how much? April 2017

152 Q41 Dr Tony O’Sullivan

153 Q206 Niall Dickson

154 Q28 Dr Colin Hutchinson

155 Q271 Simon Stevens

156 The Health Foundation, ‘Discharge to assess’ at Sheffield Frailty Unit, accessed on 2 June 2018

Published: 11 June 2018