After the Future Forum's report on integrated care, what now?

Primary care must be at the heart of the delivery of integrated care. Our recent report to the Department of Health and the Future Forum, written in partnership with Nuffield Trust, argued that for this to happen, general practice must change in two important ways.

First, practices must operate at scale to deliver integrated services and achieve effective collaboration with other clinicians. This does not mean practices relinquishing their independence. Rather, it requires them to work together in a more corporate way, recognising their collective interest, and potentially using the mechanism of federations

Second, these groups of practices must work closely with staff in community health services and social care to make a reality of joined-up care close to home. One option is for groups or federations of practices to work hand-in-hand with integrated community teams, ideally covering both health and social care. This in turn creates the potential for engaging specialists.

These proposals were echoed in this week's report from the Future Forum, suggesting that there is an emerging consensus on the new model needed to make a reality of integrated care. The challenge is how to act on this consensus when some of the policies being pursued by the government may lead to greater fragmentation rather than increased integration. A further challenge is how to find time and resources for new services when there are increasing financial and service pressures facing the NHS.

Our recent conference on integrated care showcased several impressive examples of NHS organisations, sometimes in partnership with local authorities, already delivering integrated care. These examples demonstrate what can be achieved when local leaders get on and do the right thing – despite the obstacles in the way.

To take integrated care forward, local leadership now needs to be matched by leadership in the government. Despite a pledge to develop new metrics bringing together patient experience and care co-ordination by April, the Department of Health's response to the Future Forum's report was long on warm words and good intentions but worryingly short on specific, credible commitments. The risk this creates is that integrated care will only be implemented in pockets of innovation, and that good practice will not be adopted across England.

To avoid this risk, the government should do two things: first, the mandate issued by the Secretary of State to the NHS Commissioning Board should ensure that integrated care is a high priority for the Board. As the Fund argued in its report, there needs to be a clear and measurable objective for improving integrated care, given the same priority as the 18-week waiting list target that was so influential in improving access to elective care.

Second, the government should revisit the NHS Constitution and ensure that it includes guarantees to people with complex needs. These guarantees should include people having a care plan and a care manager responsible for co-ordinating their care.

A recent briefing from National Voices underlines the importance of integrated care to patients. Only by making specific, credible commitments will ministers convince us that they are serious when they say that integrated care is a priority for the future.

Read the full report to the Department of Health and the Future Forum on integration

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Comments

#673 Don Brand

There is something quaintly old-fashioned about the Kings Fund's persistence in mounting conferences on "integrated care" which "showcase" neither social care nor, more importantly, the people who use health and care services. The Future Forum recognises the latter group are the people left to integrate fragmented care as best they can. The NHS's habit of talking to itself, usually in tones of warm congratulation, is one of the reasons it is so slow to change. Until the health service understands it needs to engage on equal terms with social care and the users of both services, there is little prospect of genuine outcomes-led integration. The obstacles that have blocked it for 40 years will remain firmly in place.

#676 calum paton
Professor (Public Policy, Health Policy)
Keele University

The NHS Future Forum?

Come off it, Chris....you're too kind to them!

The trouble is that such cosy teams tend to come up with a stodgy helping of motherhood-and-apple-pie. This report takes us back to the future - it is, in process terms, a strange hybrid of: the 'working papers' which accompanied the Thatcher Review in 1989; of the policy papers following the NHS Plan of 2000 and, as stated; and of Darzi's touchy-feely, pro-quality, pro-patient involvement riff (now remind me - who's against 'quality' and 'patient involvement'?) - and covers similar territory with little self-awareness.

Those who are unaware of history are condemned to repeat it, to paraphrase Santayana.

The Forum was born in the need for the Conservatives to reassure their Coalition partners and the public that Mr. Lansley's sudden shake-up would not lead to privatisation or indeed dissolution of the NHS. So the Forum grazed on a 'policy-lite' food...the comfort food of 'integration'.

Its first report told us that integration was just as important as competition. Yet since then, the amended Health Bill has changed surprisingly little: its institutions and incentives are all about creating an NHS which resembles a privatised utility. Or rather, since the PM ordered Lansley to accept the Forum's first report, the original 'vision' has been tempered with warm words.

One hoped therefore that the Forum's second report would get an analytical grip concerning unresolved issues: can competition and integration (or collaboration) co-exist?; are integrated organisations (covering hospital and primary care, community and social services) to be natural local providers or are they to compete with each other?; are whole NHS hospitals allowed to be 'preferred providers'; and, if not, how will we avoid the cherry-picking of services in the marketplace? What, indeed, is the difference between promoting competition (Health Bill Mark 1) and preventing anti-competitive behaviour (Health Bill Mark 2)? How can a market regulator (Monitor) suddenly become a quality-monger and service planner?

Yet all we get is a reminder that competition and integration have to be reconciled, and a quote from said regulator Monitor that, in effect, they will not allow competition where it is not appropriate.

There is a worrying trend in English health policy which academics might call ideological closure (consensus within ideological constraints) and which plain-spoken folks might simply call 'taking in each other's washing.' The Forum's second report draws on the King's Fund's and Nuffield Trust's joint work on 'integration', and the latter in turn is warm about the Forum's report. Yet this work is essentially a series of 'ad hoc' examples from around the country of where local health and social service agencies have sought to collaborate against the trend of prevailing policy. This policy derives from what one might call (apologies to the World Bank and the 'Washington consensus'!) the 'London consensus' - which emphasizes the market and in particular the 'inevitability' of the 'purchaser-provider split' between commissioners on the one hand and providers,on the other hand who are, to boot, not expected - in the default position - to collaborate.

The problem is that many of the academics who eulogised the 'purchaser/provider split' over the last twenty years are the same people who are now preaching 'integration', and seeking to square the circle by advocating competition between integrated organizations. In our constrained public finances, this latter concept is deeply problematic. There is no evidence that the Forum understands the complexity of the 'integration' issue in the present policy environment.

The House of Lords' debates on the Health Bill just before Christmas show that this environment remains the neo-liberal consensus which brings Blairites (eg Lord Warner) close to Conservative health policy.

#694 Dr David Rapp
Retired GP

I agree with the sentiments expressed by the Professor,but also with the aspirations of the King's Fund report.However,my anxiety is that the Dept of Health and their political masters have so little understanding of how their own Health service really functions,and hence any plans they put forward tend to address theiir own predetermined views and agenda.Any useful innovations tend to develop despite DOH regulation,not because of it.Andrew Lansley has to be much more upfront about how the myriad of issues presented by both Health workers and Think Tanks,can be solved by his proposals,rather than suggest they have vested interests.My own feeling is that the present financial arrangements do not reflect how medical services need to develop,and are not flexible enough to aid the prospect.I am very concerned that all the energy and time needed to work on these issues will be swamped by the artificial agenda concocted by the Government to satisfy their slightly perverted sense of how the services should be organized

#1049 Susan McCann
Parent/carer

I have a son with high functioning autism, moderate learning difficulties and a complex cluster of medical conditions, including Type 1 diabetes and other endocrine problems. He is determined to live independently and has recently moved to a supported living project - the third time of trying.

The other two projects failed because care workers didn't have the knowledge to understand his medical needs; and NHS clinicians are not used to working proactively with care workers and hide behind their budgets! (Not my job guv!) The NHS are reactive and not proactive. Simply put, medicine moves on apace and many children and adults are now living much longer in our communities than previously expected but this of course impacts on whether the needs of such people can be appropriately met, and by whom and who is doing the training.

Whilst I remain my son's main carer, of course I will continue to be a part of the caring team, but as a lady in her 60s it is imperative that everyone works towards the day when I will no longer be able to do so.

At every opportunity I raise this as a major issue for my son and of course he is one of many in the community who are fine whilst the family or other carers continue to care, but if this support fails through death or ill health, the current contracted care workforce are not equipped to continue the care and NHS clinicians (District Nurse, Community Matron, Diabetes Nurse Specialists, GP, Practice Nurse) seem at a loss as to know what would happen if I disappear!

I recently attended an East of England NHS Personalisation event and sat next to someone who works for Skills for Care (oh that Skills for Care would join up with Skills for Health!) who told me about hybrid careworkers, people who span both "health and social care" who receive training to deal with conditions such as diabetes and other long term conditions.

I agree that it is time to stop pontificating and get on with creating because fiddling around whilst Rome burns springs to mind. We the patients and carers have been saying for years that health and social care must work together and the economics of everyone in harmony working in the best interests of the patient/client to prevent deterioration in health and hospital admission makes the most sense of all. There are unmet needs in the community for people like my son who needs day to day carers to have specialist skills as I have described. Leaders are one thing but at the sharp end, my son needs people who have the skills and competencies that would make the personalisation agenda a reality for him - oh, and in my lifetime would be nice, too!

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