Integrated care: organisations, partnerships and systems Contents

Conclusions and recommendations

Integrating care for patients

1.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. (Paragraph 12)

Progress towards more integrated care

2.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. (Paragraph 41)

3.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. (Paragraph 42)

4.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. (Paragraph 43)

5.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. (Paragraph 44)

Sustainability and transformation boundaries, plans, partnerships and integrated care systems

6.STPs got off to a poor start. The short timeframe to produce plans limited opportunities for meaningful public and staff engagement and the ability of local areas to collect robust evidence to support their proposals. Poor consultation, communication and financial constraints have fuelled concerns that STPs were secret plans and a vehicle for cuts. These negative perceptions tarnished the reputation of STPs and continue to impede progress on the ground. National bodies’ initial mismanagement of the process, including misguided instructions not to be sharing plans, made it very difficult for local areas to explain the case for change. (Paragraph 64)

Sustainability and transformation boundaries

7.An STP area, or areas within it, work more effectively where they are meaningful to partners, local health professionals and most importantly the public. STPs, particularly those with more complex geographical boundaries, should be encouraged and supported to allow local areas to identify, define and develop meaningful boundaries within their patch in which local services can work together around the needs of the population. (Paragraph 73)

8.STPs should be encouraged to adopt a principle of subsidiarity in which decisions are made at the most appropriate local level. NHS England and NHS Improvement should set out in their planning guidance for 2019/20 advice and support to achieve these recommendations. (Paragraph 74)

Sustainability and transformation partnerships

9.Sustainability and transformation partnerships provide a useful forum through which local bodies can come together in difficult circumstances to manage finite resources. However, they are not on their own the solution to the funding and workforce pressures on the system. We are concerned that these pressures, if not adequately addressed, may threaten the ability of local leaders to meet their statutory obligations let alone transform services. Overwhelming and unrealistic financial pressure drives them to retreat back to organisational silos. This would seriously undermine the progress local leaders have made in already difficult circumstances. (Paragraph 91)

10.We recommend that the national bodies, including the Department, NHS England, NHS Improvement, Health Education England, Public Health England and CQC, develop a joint national transformation strategy. This strategy should set out clearly how national bodies will support sustainability and transformation partnerships, at different stages of development, to progress to achieve integrated care system status. This strategy must not lose sight of patients. National bodies in this strategy should:

Integrated care systems

11.We support the development of integrated care systems, including plans to give greater autonomy to local areas as part of their ICS status. We are encouraged by the positive progress the first 10 integrated care systems have made in the face of challenges on the systems. However, like STPs more generally, we are concerned that funding and workforce pressures on these local areas may exacerbate tensions between their members and undermine the prospect of them achieving their aims for patients. (Paragraph 105)

12.NHS England and NHS Improvement should systematically capture and share learning from areas that are furthest ahead, including their governance arrangements and service models, to accelerate progress in other areas and also to provide clarity about what is permissible within the current legal framework. (Paragraph 106)

13.We recommend, as part of a joint national transformation strategy, that national bodies clarify:

a)how they will judge whether an area is ready to be an ICS;

b)how they will support STP areas to become ICSs;

c)what they will do in areas that fail to meet the criteria;

d)how they will monitor the performance of existing ICS areas and provide support including the necessary funding to ensure they continue to make progress; and

e)how they will address serious performance problems in ICS areas. (Paragraph 107)

14.Given the controversy surrounding the introduction of accountable care organisations in the English NHS, we believe piloting these models before roll-out is advisable. There should be an incremental approach to the introduction of ACOs in the English NHS, with any areas choosing to go down this route being carefully evaluated. (Pargraph 140)

15.The evaluation of ACOs should seek to assess:

We do not believe it is in the best interests of patients to return to a system devoid of choice. (Paragraph 141)

Accountable care organisations

16.We recognise the concern expressed by those who worry that ACOs could be taken over by private companies managing a very large budget, but we heard a clear message that this is unlikely to happen in practice. Rather than leading to increasing privatisation and charges for healthcare, we heard that using an ACO contract to form large integrated care organisations would be more likely to lead to less competition and a diminution of the internal market and private sector involvement. (Paragraph 155)

17.We recommend that ACOs, if a decision is made to introduce them more widely, should be established in primary legislation as NHS bodies. This will require a fundamental revisiting of the Health and Social Care Act 2012 and other legislation. Whilst we see ACOs as a mechanism to strengthen integration and to roll back the internal market, these organisations should have the freedom to involve, and contract with, non-statutory bodies where that is in the best interests of patients. (Paragraph 156)

18.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. (Paragraph 167)

Making the case for change to the public

19.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. (Paragraph 181)

20.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. (Paragraph 182)

21.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. (Paragraph 183)

22.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. (Paragraph 184)

23.There has not been a sufficiently clear and compelling explanation of the direction of travel and the benefits of integration to patients and the public. National and local leaders need to do better in making the case for change and how these new reforms are relevant to those who rely on services. The language of integrated care is like acronym soup: full of jargon, unintelligible acronyms and poorly explained. (Paragraph 202)

24.The Department of Health and Social Care and national bodies should clearly and persuasively explain the direction of travel and the benefits of these reforms to patients and the public. We recommend the Department and national bodies develop a narrative in collaboration with representatives of communities, NHS bodies, local government, national charities and patient groups. The messaging should be tested with a representative sample of the public. A clear patient-centred explanation, including more accessible, jargon-free, language, is an essential resource for local health and social care bodies in making the case for change to their patients and wider communities. (Paragraph 203)

25.Making the transition to more integrated care is a complex communications challenge covering a range of different services and patient populations. The case for change must be made in a way that is meaningful to patients and local communities. In addition to providing a clear narrative, in accessible language at a national level, the Department of Health and Social Care, NHS England and NHS Improvement should explain how they plan to support efforts to engage and communicate with the public. (Paragraph 204)

26.NHS England and NHS Improvement should make clear that they actively support local areas in communicating and co-designing service changes with local communities and elected representatives. (Paragraph 205)

27.Bringing local health and social care services together through STPs and ICSs to plan and organise care within their footprints is a much better way to manage constrained resources than the siloed, autonomous and competitive arrangements imposed by the Health and Social Care Act 2012. Our view is that STPs and ICSs are a pragmatic response to the current pressures on the system, rather than a smokescreen for cuts, but that these mechanisms are not a substitute for adequate funding of the system. Funding them properly, including access to ring-fenced transformation money, is necessary and would allow a far better assessment of their potential. (Paragraph 207)

Funding and workforce challenges

28.The NHS and local government have not been given adequate investment, support and time to embark on the scale of transformation envisaged. Transformation depends not only on having sufficient staff to maintain day-to-day running of services, but in the capacity and capability of staff to redesign services, engage in dialogue and consultation and develop new skills. Transformation also requires funding the staff costs associated with double-running new services, while old models are safely decommissioned. (Paragraph 231)

29.The Government’s long-term funding settlement should include dedicated, ring-fenced funding for service transformation and prevention. We recommend that the Government commit to providing dedicated transformation funding when it announces its long-term funding settlement this summer. (Paragraph 232)

30.The task of determining the scale of funding and the most appropriate ways to allocate and manage such resources is a complex challenge. To inform this work we recommend:

National oversight and regulation

31.To assess whether the commitments by NHS England and NHS Improvement to align priorities and incentives at national level have made a tangible difference to those on the frontline, we encourage those organisations to conduct a joint survey one year after their announcement on 27 March 2018. The real test will be whether this makes a positive difference at local level. (Paragraph 242)

32.Local bodies’ experience of their national counterparts is one of competing priorities that perpetuate existing divides between services and encourage organisations to retreat into individual silos. While this appears to be improving, we have not heard clear and compelling evidence that the interventions of national bodies reinforce and enable more integrated, place-based care. Incoherence in the approach of national bodies is a key factor holding back progress. (Paragraph 265)

33.We heard, and saw, outstanding examples of great care that frontline services have been able to build, implement and maintain even in periods of constrained resources. We also heard of promising results from the new care models programme. However, how national bodies plan to scale up and spread best practice and accelerate transformation across the system remains unclear. (Paragraph 266)

34.We recommend that the Department of Health and Social Care and national bodies, particularly NHS England, NHS Improvement, Health Education England and the Care Quality Commission, clearly describe as part of a national transformation strategy how each of the bodies will work together to support transformation. (Paragraph 267)

35.We request a joint response from the Department of Health and Social Care, NHS England, NHS Improvement, Health Education England and CQC setting out, against each of the following headings, how their roles, responsibilities, functions and policies support the following factors that are critical to transformation and integrated care.

The response should include details of plans the national bodies have over the next year to make progress on each of these areas. (Paragraph 268)

36.NHS England and NHS Improvement should systematically capture, distil and disseminate key lessons from the local areas that are furthest ahead, including the governance arrangements and service models used in these areas. Careful attention should be played to striking a balance between learning from the frontrunners and not overburdening these areas. We recommend that NHS England and NHS Improvement undertake a review of the first cohort of integrated care systems starting in April 2019, and make the key findings available to all STP areas. That should include the level of financial support underpinning transformation. (Paragraph 269)

Governance and legislation

37.Positive progress has been made within the constraints of the current legislative framework but sometimes requiring cumbersome workarounds. Our view is that national and local leaders have had little room for manoeuvre in which to transform care. We are concerned that many local areas are operating with significant risks in terms of their governance and decision-making. (Paragraph 295)

38.The law will need to change. We recommend that Parliamentarians across the political spectrum work together to support the legislative changes to facilitate evolutionary change in the best interests of those who rely on services. (Paragraph 297)

39.The Department and national bodies should adopt an evolutionary, transparent and consultative approach to determining the future shape of health and care. The Department and NHS England should establish an advisory group, or groups, comprised of local leaders from across the country, including areas that are more advanced and those further behind, and representatives from the health and care community, to lead on and formulate legislative proposals to remove barriers to integrated care. The proposals should be laid before the House in draft and presented to us to carry-out pre-legislative scrutiny. (Paragraph 298)

40.The purpose of legislative change should be to address problems which have been identified at a local level which act as barriers to integration in the best interest of patients. We wish to stress again that proposals should be led by the health and care community. (Paragraph 299)

41.Evidence we have heard from representatives from NHS and local government has identified the following legislative areas that may need to be considered:

a)A statutory basis for system-wide partnerships between local organisations;

b)Potential to designate ACOs as NHS bodies, if they are introduced more widely;

c)Changes to legislation covering procurement and competition;

d)Merger of NHS England and NHS Improvement; and

e)CQC’s regulatory powers.

Where barriers are identified and can be removed with secondary legislation, this may represent a less complex way forward. (Paragraph 300)

42.Until legislation is introduced, national bodies should support local areas to develop transparent and effective governance arrangements that allow them to make progress within the current framework. National bodies should also provide greater clarity over what is permissible within current procurement law and develop support for local areas in working through these issues. National bodies should set out the steps they plan to take to provide clarity, guidance and support to local areas on these matters in response to this report. (Paragraph 301)





Published: 11 June 2018