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June 2018 marked a year since the first integrated care systems (ICSs) were announced. Over the past few months, The King’s Fund has been exploring how eight of these ‘first wave’ ICSs have developed – who has been involved, what leadership and governance arrangements have been put in place, and how the ICSs have been working with national NHS bodies. Of course, one of the most important questions for our research was – what difference are ICSs making to services?
A year in, the ICSs are still at the beginning of their journey and improvements in services are only just emerging. It’s important to be realistic about how quickly changes can be achieved, and mindful of the risks of expecting too much, too soon. As one of our interviewees told us:
'If you try and race towards the perfect end point, you'll probably never get there, and that can be demoralising… Systems ought to establish, ‘What is it that we're going to actually achieve in the next few months and does that take us broadly in the direction that we want to go in?’
That’s not to say that improvements aren’t underway. We found that ICSs are focusing on service changes at multiple levels. Work in neighbourhoods – which typically cover populations of 30,000 to 50,000 – is focused on integrating primary care, community services, mental health services and adult social care. This involves services working together to develop community-based responses to the needs of their local populations. At a ‘place’ level – often defined by a local authority, clinical commissioning group or acute trust footprint – the focus is on work around improving links between acute and other providers. It’s also the level at which local authority engagement tends to be strongest. The system level carries out activities that are best performed at scale, such as work on specialist services, acute reconfigurations, workforce, and estate and IT. Work at each of the levels is key to delivering integrated care.
We heard about some common areas of focus. All areas are strengthening primary care services, with GP practices coming together in networks or federations to stabilise GP services and improve access for patients. In Luton, an intensive primary care change programme is under way, involving leadership forums of networks of practices working to deliver care differently for specific population groups. Across the ICSs, those we spoke to saw developments such as these as fundamental to overall success, with sustainable primary care services as ‘the bedrock’ of more integrated care.
Many areas are also working to develop community hubs or integrated care teams, which bring together a range of health and care professionals – GPs, community nurses, social care workers, mental health professionals, voluntary sector workers and others – to provide proactive care and support individuals with their wider needs. Changes are intended to support a shift of care out of acute settings and into the community. A community hubs pilot in Buckinghamshire has developed a community assessment and treatment service, additional diagnostic facilities and an extended range of outpatient clinics. An evaluation found promising signs of progress, including a reduction in non-elective admissions via GP referral for people aged over 75.
Although there are fewer examples of changes to acute services, some ICSs are carrying out important work to improve the way that hospital services are delivered across the local system. Changes involve increased collaboration between acute providers, for example, through flexible staff working, shared clinical strategies, and the centralisation of some specialist services. In South Yorkshire and Bassetlaw, acute service reconfigurations are planned following an independent review of services across seven hospitals. In Dorset, there are plans to relocate specialist services across Poole Hospital and Royal Bournemouth Hospital.
Other changes – such as the Dorset Care Record and the Connected Care programme in Berkshire West and Frimley – aim to improve information-sharing across local systems. The Connected Care programme provides health and care professionals with instant access to patient information by bringing together records from 18 health and social care organisations and 135 GP practices into a single shared care record.
There’s also work going on to improve preventive care, for example, through social prescribing and extended roles for community pharmacy. This included a pharmacy screening initiative in Bedford, Luton and Milton Keynes, aimed at improving detection of hypertension and atrial fibrillation. However, interviewees told us that working on prevention was currently an aspiration or needed further work.
While there are many changes under way, or planned, those we spoke to were clear that delivering measurable outcomes is a key priority going forward. Demonstrating progress will be vital in maintaining and building engagement with ICSs, not only throughout the organisations involved but among their partners, patients and the public. While there was clear support for the ICS model from those we interviewed, there is also a recognition of the need demonstrate and communicate the value of ICSs more widely. As one interviewee explained, the ‘next steps are actually to demonstrate quick wins… People are already starting to buy into the concept more... But there’s a big “hearts-and-minds” thing to do’.