What we think
People too often receive fragmented care. This can have a negative impact on their experiences, lead to poorer outcomes, and create duplication and inefficiency within the system. Better integrating services within the NHS and across health and social care has the potential to improve people’s outcomes and experiences of care, particularly for those in contact with different services, including growing numbers of older adults and people living with multiple long-term conditions.
Integration has been an objective of national policy for more than three decades, but progress towards delivering these ambitions has been slow. Most patients and service users are not yet feeling the benefits despite more than three decades of ambition and countless policy initiatives. Despite the rhetoric around integration, this has not been followed through by implementing ways of planning, paying for and regulating services to support organisations to work together. Market-based reforms to embed organisational autonomy and competition in the NHS have, in fact, had the opposite effect. Efforts to join up health and social care have been held back by fundamental cultural and structural differences between the two systems. National and local leaders need to work together to overcome these barriers to support local integration.
The NHS five year forward view and more recently the NHS long-term plan set out a welcome vision of joined-up services and a system built around collaboration rather than competition. Integrated care systems (ICSs) and primary care networks (PCNs) are the main mechanism for implementing these ambitions, offering an important opportunity to turn the rhetoric around integrated care into reality. To be successful, ICSs will need to look beyond the NHS and fully involve local authorities as equal partners as well as involving the voluntary and community sector and others.
As integrated care develops, the understandable desire to see change happen quickly needs to be tempered with realism about what can be achieved. Change of this scale and complexity will take time to deliver, and it is not realistic to expect integration of local services to lead to reductions in demand for hospital services or financial savings, at least in the short term. The health and care system currently has no effective way of measuring how well services are integrated, and better measures are needed to reflect whether people are receiving joined-up, personalised care.
The health system was set up to provide episodic treatment for acute illness, but it now needs to deliver joined-up and proactive support for growing numbers of older people and people living with multiple long-term conditions and complex needs. The way the NHS is organised is based around separate organisations working autonomously, reflected in the way that services are contracted and paid for, and the way that providers and commissioners are inspected and regulated. This makes it difficult to join up services across different parts of the NHS. Separate IT systems and a lack of information-sharing have also made it harder for staff working in different services to communicate and coordinate their care.
Joining up services across health and social care is even harder due to the fundamental fault line between NHS services, which are free at the point of use, and social care services, which are means and needs tested, and efforts to integrate care have often paid insufficient attention to the role of local authorities.
There is no single definition of integrated care and services can be joined up in different ways, for example across hospital and community-based care, physical and mental health care and health and social care.
Integrated care is now being pursued in England through the development of PCNs – groups of GP practices and other community-based services working together to deliver improved services to populations of 30–50,000 – sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) – local ‘place-based’ partnerships of NHS and local authority organisations. Nascent PCNs are now in place across the country, and the NHS long-term plan committed to ICSs covering all areas of England by April 2021. These changes rely on collaboration between different organisations but are taking place within legal, financial and performance frameworks designed to promote organisational autonomy and competition. This presents a challenge and the national NHS bodies have proposed changes to the law to accelerate progress.
There are high expectations in the NHS long-term plan about what integrated care will achieve. However, evidence shows that success is highly dependent on local context and results often take years to materialise. Integration does not necessarily save money, but it can lead to improved experience and outcomes for patients and service users. Current ways of measuring performance and holding the health and care system to account do not adequately reflect people’s experiences of whether the services they receive are joined-up, and the system needs better measures in place to assess this.
Until recently, the main focus of integrated care has been on bringing different parts of the NHS closer together, as well as strengthening relationships between health and social care. Yet there is a large volume of evidence that social determinants such as housing, education, employment and social connectedness, have a greater impact on health and wellbeing than health and care services. There is therefore a strong case for strengthening connections between the NHS and other services to create ‘population health systems’. This will require collaboration between NHS organisations, local authorities, the third sector and other local partners including the local community.