Integrated Care

‘Integrated care’ has become something of a buzz-word, but what it means depends on who’s talking.

There is widespread recognition – for example among health care practitioners – that patients benefit from being involved in decisions about their care and, if they need care across different settings (such as in hospital and then when they have been discharged home), if that care can be provided in a seamless kind of way. In this view, integrated care may improve the patient’s experience of healthcare because it’s being planned from their perspective.

There is also increasing recognition of the benefits of integrating health and social care services, including some degree of sharing of their resources and maybe commissioning. Better integrated services might, for example, mean hospital patients can be discharged sooner by facilitating the appropriate services at home to support them, so saving money and improving patient experience. However, cuts to council funding and increasing financial constraints on NHS bodies are making it hard to move towards the integration of health and social care, when frontline staff are struggling to keep existing services running. (See http://www.communitycare.co.uk/2016/05/13/cuts-making-difficult-achieve-health-social-care-integration-warns-research/).

‘Integrated care’ is also used by policy makers, politicians and others as a way of redesigning health services. For instance, its been used as one of the reasons for a top-down move towards devolving the funding and assets of public services such as the NHS from central government to unelected, combined local authorities (See our page on Devolution and the NHS for more details).

At the same time, NHS England has introduced plans aimed in part to integrate care by restructuring the NHS. These plans introduce ‘new care models’ or organisations that bring together different services (such as GP, specialist and social care services) and different budgets (such as NHS and Local Authority budgets) – see our section on NHS England’s Five Year Plan for more on these.  This kind of integrated care may partly aim to maintain or improve the quality of services,  but it’s also about cutting costs.

It appears that, ultimately, these models of care will be financed by new arrangements such as ‘capitated payments’ (or a fixed payment for each registered patient), a system that could pave the way to developing the kind of ‘managed care’ found in the US. In fact, some people equate ‘integrated care’ with ‘managed care’.

Managed care is often explained as a system of providing quality care while reducing its cost. The kinds of measures used to do this include giving clinicians financial incentives to use less costly forms of treatment, having higher thresholds for referring patients for investigation and putting controls on hospital admissions and lengths of stay. In the US, managed care can be provided through different ‘models of care’, such as Health Maintenance Organisations, where registered patients are given access to a network of services and staff in exchange for a subscriber fee (or premium).

There is concern that restructuring of the NHS towards these new models of care makes it possible to shift the NHS from a service that covers the cost of treating all medical problems to an insurance-based system with limited entitlement to care, similar in some ways to the US health system. This fits with a growing number of calls from some quarters for NHS treatment to be financed by private health insurance. For example, before the 2015 general election, the various political parties spoke of their commitment to a tax-funded NHS. But a couple of months later, a debate in the House of Lords on the sustainability of the NHS cast doubt on these assurances with, for example, suggestions that the government should ‘help the public to think of other ways to pay for healthcare”, whether this was through compulsory insurance or certain charges. (see https://opendemocracy.net/ournhs/richard-grimes/government-moves-to-consider-nhs-user-charges). (See also our pages on A Long Term Plan and Sustainability)

Currently, NHS care is paid for by taxes and provided according to need while social care is means tested. It’s very possible – especially given severe cuts in funding for local authorities – that the integration of health and social care will be used as a justification by combined authorities for extending means testing or introducing some other form of charging for NHS care.

Recently, NHS England has suggested that one way of integrating care is through the joint commissioning of primary care (i.e. the joint planning and buying of GP services by Clinical Commissioning Groups (CCGs) and NHS England):

“Co-commissioning is a key enabler in developing seamless, integrated out-of-hospital services based around the needs of local populations”.

What’s more, co-commissioning

“will help drive the development of new integrated models of care such as multispecialty community providers and primary and acute care systems.”            https://www.england.nhs.uk/2015/03/joint-gp-services/

In addition, NHS England has now designed a way to bring its Five Year Plan rapidly into effect and integrate health and social care by 2020. It has restructured the NHS and local authorities in England into 44 different local economic systems or ‘footprints’ that aim to integrate health and social care services. Each footprint is expected to produce Sustainability and Transformation Plans to show how they will reduce the need for services and cut costs, as well as how they will maximise efficiency. These plans will also be assessed on other measures, such as whether they include new care models, or expand the use of integrated personal budgets to cover both health and social care needs.

Significantly, despite all this talk of integration,

“… something else is barely mentioned these days: an integrated National Health Service, with integrated national clinical standards, nationally recommended treatments, national accountability, integrated funding through general taxation, integrated methods of allocating resources to areas of greatest need, an integrated national system of pay, terms and conditions for health service staff.”

(https://www.opendemocracy.net/ournhs/greg-dropkin/nhs-is-headed-for-devolution-iceberg-whilst-mps-argue-about-deckchairs)

In February 2017, the National Audit Office (NAO) produced a report warning that progress with integrating health and social care has, so far, been slower and less successful than imagined, and that it had not brought the expected benefits for patients, the NHS or local authorities. It suggests that the government’s plan for integrated health and social care services across England by 2020 is at significant risk.

While the NAO understands that there is agreement across the health and social care sectors that ‘place-based’ planning is the right way to manage the NHS’s scarce resources, local government has not always been fully involved in the design and development of the STP programme.

The NAO’s report also found that NHS England’s ambition to save £900 million through introducing new care models may be optimistic. The new care models are as yet unproven and their impact is still being evaluated. According to the NAO, there are an array of initiatives examining different ways to transform care and create financial sustainability, but the governance and oversight of these initiatives is poor. What’s more, the NAO found no strong evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity.

Sources and further information

NHS England’s Five Year Forward View http://www.england.nhs.uk/ourwork/futurenhs

The Lords debate on the sustainability of the NHS https://opendemocracy.net/ournhs/richard-grimes/government-moves-to-consider-nhs-user-charges

https://www.nao.org.uk/report/health-and-social-care-integration/ 

Updated November 2016

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