It is certainly true that an over-reliance on hospital-based care, and the political reluctance to challenge this, has long been a barrier to necessary change in health systems across the world. Jean Rebert, one of the principal architects of the PRISMA integrated care system in Quebec, Canada, has made this case forcefully. Speaking at the World Congress on Integrated Care in Sydney last year, he said that in his experience the greatest obstacle to integrated care is the political attractiveness of prioritising investment in hospitals over other forms of care.
However, while integrated care clearly means change for hospital-based professionals, it is not by definition opposed to the institutional interests of hospital providers. A growing number of acute trusts in England are actively engaging with integrated care, seeing this as not only compatible with their interests, but as an essential part of the ongoing financial sustainability of the services they provide.
Several acute trust leaders involved in our research described a new understanding of their role in the health system. Rather than seeing their role as being limited to managing an institution, they now see it as incorporating a wider concern for the performance and sustainability of health and care services across the local system. In part this system-wide perspective is born out of mutual dependency and a recognition that hospitals will only be able to manage the increasing demand they face by working more closely with local partners.
While this change in perspective is welcome, we must be careful not to reduce integrated care to a tactic for managing financial pressures in the hospital sector. Integrated care is about much more than improving the efficiency of discharge processes from hospital into the community – important though that is. As some of my colleagues have recently argued, the endpoint for integrated care is for a wide range of organisations (including partners beyond health and social care itself) to work together closely in promoting health and preventing avoidable disease in the populations they serve, in addition to providing well co-ordinated care for those who need it.
One of the most contentious questions is whether new models of care will allow commissioners to radically reduce the number of hospital beds in the system. International examples, such as the transformation of health services in Canterbury, New Zealand, do not offer much cause for optimism here. The benefits of more integrated working may be offset, at least in the immediate future, by rising levels of demand created by the ageing population. However, what integrated care may enable the system to do is to manage this increasing demand without needing further increases in hospital capacity.
While integrated care certainly does not spell the end for acute hospitals, and may not lead to much reduction in their size any time soon, it will entail significant changes in terms of care pathways, workforce arrangements and organisational models. Integrated care requires acute care professionals to be willing to rethink the way that they provide services, with more care being delivered beyond the hospital walls and an increased role in prevention and population health. Closer co-ordination with primary care, community services and social care will be needed, potentially delivered through new organisational forms as discussed in the Dalton review and the NHS five year forward view. That will involve grappling with some tricky technical and contractual issues as well as overcoming cultural differences between professions.
After several years of highly distracting reforms to the commissioning and system management structures in the health service, the NHS five year forward view has rightly shifted attention back to the place where change is really needed – the provider side. Bringing about the new models of care that it describes will inevitably be a disruptive process in many parts of the country, including for hospital providers. What is important is that this process does not descend into territorial squabbles between ‘primary care-led’ and ‘hospital-led’ models of integration. Hospitals should be neither demonised nor dominant but will certainly need to be part of the discussion.