What we think
People too often receive fragmented care from services that are not effectively co-ordinated around their needs. This can negatively impact their experiences, lead to poorer outcomes, and create duplication and inefficiency. Integrated care – joining up services within the NHS and across health and social care – has the potential to improve people’s outcomes and experiences of care, particularly for older people and those who have multiple long-term conditions and use a number of different services.
Integration has been an objective of national policy for more than three decades, but progress towards delivering it has been slow. Previous market-based reforms to the NHS have incentivised competition between autonomous organisations rather than collaboration across systems. Efforts to join up health and social care have been held back by fundamental structural and cultural differences between the two systems.
The NHS Five Year Forward View, the NHS Long Term Plan and more recently the Health and Social Care White Paper set out a welcome vision of joined-up services and a system built on collaboration rather than competition. This agenda has been taken forward by integrated care systems (ICSs), which bring together providers and commissioners of NHS services with local authorities and other local partners to plan health and care services in 42 areas across the country. ICSs offer an important opportunity to improve population health through genuine partnership working between the NHS, local government, the voluntary and community sector and local communities.
The proposals in the White Paper have now been passed as part of the Health and Care Act, which came into effect from July 2022. We welcome the Act, which sets out a legislative framework to support collaboration and make further progress in integrating care by putting ICSs on a statutory footing. However, these are complex reforms and it is vital that they are underpinned by a clear narrative describing how they will benefit patients, service users and communities. Working alongside National Voices, Age UK and the Richmond Group of charities, we have developed a joint vision that sets out how the reforms can improve health and care.
It is important to recognise the limits of what legislation can achieve. Success will depend on implementation, with behaviours and relationships that support collaboration needing to be developed, nurtured and modelled right across the health and care system, including within national bodies. Evidence from previous attempts to integrate care indicates that these changes will take time to deliver results – local and national leaders need to make a long-term commitment to change and avoid the past mistake of moving swiftly on to the next reorganisation if desired outcomes are not rapidly achieved. Listening to patients and communities will also be key to improving services and understanding how efforts to join up care are progressing.
The context
The health and care system needs to deliver joined-up, proactive support for growing numbers of older people and people living with multiple long-term conditions. But the NHS is structured around separate organisations working autonomously, which is 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.
Joining up services across health and social care is even harder due to the fault line between NHS services, which are free at the point of use, and social care services, which are means and needs tested. Past 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 between primary and secondary care, physical and mental health care and health and social care. In many areas, the response to Covid-19 underlined the power of system working, which took many forms including mutual aid between NHS providers, work with voluntary and community organisations or closer engagement with local government.
Integrated care in England is now being pursued through ICSs. Since April 2021, all parts of England have been covered by one of 42 ICSs. They are underpinned by joint working at ‘place’ level, which is where much of the heavy lifting of integration takes place, driven by ’place-based partnerships’ involving NHS organisations, local authorities, voluntary and community sector organisations and local communities across a smaller footprint than an ICS, often based on the area covered by a local authority. These are complemented by initiatives at neighbourhood level, where primary care networks (groups of GP practices and other community-based services) work together to deliver improved services to populations of 30–50,000. Other non-statutory partnerships, such as provider collaboratives, are also set to become a key part of the arrangements across health and social care. These partnership arrangements encourage organisations to work together and focus on system-wide objectives and improving outcomes for the communities they serve.
In early 2021, the Department of Health and Social Care published a White Paper that included the legislative proposals now incorporated in the Health and Care Act. The Act entered parliament in July 2021 and came into effect in July 2022. In addition to setting out a statutory framework for ICSs, it will remove some of the legal and financial rules that have hampered integrated care. This includes changes to the competition and procurement rules, which could give ICSs greater flexibility to deliver joined-up care to the increasing number of people who rely on multiple services.
The government has also signalled that while ICSs and the measures in the Act are a step in the right direction to better integrate care, they intend to go further and co-produce a comprehensive national plan for supporting and enabling integration between health and social care. This plan will focus on creating the right local incentives for integration and prevention and breaking down the barriers between services.
