The King's Fund verdict is our take on the big questions in health and social care. Here we take a look at how far the coalition government has gone in its efforts to develop integrated health and social care services.
The issue in a nutshell
Health and social care is too often fragmented, with services based on professional and institutional boundaries when it should be co-ordinated around the needs of patients. Our ageing population and the changing patterns of disease mean that growing numbers of people with multiple long-term conditions require services that are joined up, and a number of policy initiatives in England over recent years have attempted to tackle this by promoting closer integration of health and care services. Despite this, integrated care remains the exception rather than the norm.
Integrated care was not originally a major part of the coalition’s plans for NHS reform. Yet, as a result of its troubled passage from White Paper to law, the Health and Social Care Act 2012 introduced a number of changes designed to promote the closer integration of services.
Various organisations were given duties to promote integrated care, including Monitor, which was told that its role in supporting integration should ‘trump’ its role in applying competition rules. Health and wellbeing boards were created and were tasked with assessing their local population’s needs, developing a joint health and wellbeing strategy, and promoting greater integration of health and care services. The boards were made up of representatives from local authorities, clinical commissioning groups and local HealthWatch organisations, as well as any other members chosen by local areas.
While the creation of health and wellbeing boards was widely welcomed, their impact and influence so far has been variable, and generally limited. More work is needed to understand how these boards are developing as they grow into their roles.
The Care Act 2014 also placed a duty on local authorities to promote the integration of care and support services with health services (and health-related services like housing) where this will benefit patients and quality of care.
The Better Care Fund
In the 2013 Spending Round, the government announced a new pooled fund of £3.8 billion to try to encourage health and social care organisations to co-ordinate their services. This came to be called the Better Care Fund, and built on the government’s commitments in 2010 to pool some local funds for developing integrated services.
While the Better Care Fund was a new initiative, it contained no new money – only reallocations of existing funds and transfers from the NHS budget. Local areas were asked to develop plans for how they would spend their allocation of the fund, and these plans had to be approved by their health and wellbeing boards and NHS England.
Originally, a proportion of payments from the Better Care Fund was going to be made to local areas in stages to reflect performance in improving local services through integration. Following a redesign of the fund in 2014, the priority shifted to reducing emergency hospital admissions, with money staying in the NHS if these targets are not met.
The impact of the Better Care Fund will not be known until local plans have been implemented (from April 2015). However, the government’s initial optimism that these plans will reduce emergency hospital admissions (by around 3 per cent nationally) and save money (around £500 million in the first year) is not supported by evidence or recent experience. The House of Commons Public Accounts Committee recently concluded that it will not be possible to meet these objectives and that the programme’s poor planning had resulted in wasted time, money and effort.
At the same time, there’s no doubt that the Better Care Fund has facilitated some closer working (albeit mandated) between those tasked with developing joint plans for integration – particularly commissioners, who have collectively boosted the Better Care Fund from £3.8 billion to around £5.3 billion through local top-ups.
Integrated care ‘pioneers’
At the end of 2013, the government named 14 areas in England as integrated care ‘pioneers’. These areas were selected based on the strength of their plans for co-ordinating local services and have been given support from national bodies to help implement these plans. Just over a year later, 11 further pioneers were announced.
A number of the pioneers have made progress in developing more integrated services, although it’s hard to attribute these successes directly to the government’s programme, as much of their work to co-ordinate services has been underway for many years. Other pioneers have made less progress, and early evaluation suggests that it is too soon to tell whether the pioneers will be able to act as role models for the rest of the health and care system.
Devolved responsibility for health and social care spending
At the end of the parliament, the government announced plans to devolve responsibility for health and social care spending (totaling £6 billion) to statutory organisations in Greater Manchester. A memorandum of understanding approved by the Chancellor and the Health Secretary described the strategic intent for commissioners and providers to work together to develop more integrated services. This built on the Total Place and the Whole Place Community Budget initiatives introduced by the current and previous governments.
While these plans need further detail, they represent a bold initiative that could bring substantial benefits if implemented well. They also begin to move the national debate about integrated care towards the bigger prize of improving population health.
New models of care
Outside of government, NHS England and other national bodies published the NHS five year forward view (Forward View) in October 2014, which set out a shared vision for how services need to change in the future. At the heart of this vision were a number of new models of care in which services are much more integrated than they are today. More than 260 organisations and partnerships expressed an interest in developing these new care models; 29 of these were selected as the first wave of ‘vanguards’ to implement these new approaches. The Forward View was welcomed by government, who promised some investment to help support the plan’s implementation.
More broadly, many communities in different parts of the country have already begun or continued their efforts to develop new models of integrated care – particularly for older people and those with complex needs – over the past five years. A number of areas have also begun to explore new ways of commissioning and contracting to support the development of more integrated models of care.
The King’s Fund verdict
Assessing the impact of these changes is difficult, not least because efforts to develop integrated services often take a number of years, and transformation from fragmented to integrated care is rarely linear. As well as this, the impact of the government’s wider health reforms has often pulled the system in the opposite direction to integrated care.
In particular, changes made to the structure of the NHS have introduced greater fragmentation to the way that services are commissioned, making it harder to align incentives between different providers. The Barker Commission highlighted the consequences of national differences in funding and entitlements between the NHS and social care. Other well-known policy barriers to the development of integrated care also remain, including: payment systems that reward organisational activity rather than collective outcomes; regulation that focuses too heavily on organisational performance rather than system performance; and the lack of a single outcomes framework to promote joint accountability for integrated care.
Whatever their impact in practice, there’s no doubt that that the changes introduced by the coalition government have helped to embed integrated care as a common part of the language of health and social care service reform in England. Continuing to convert this language into action must be a priority for an incoming government.