‘Integrated care’ has become something of a buzz-word, but what it means depends on who’s talking.
There’s widespread recognition that patients may need care across different settings (such in hospital, and then either community or social care when they are discharged), and that this care needs to be provided in a seamless kind of way. This type of integrated care at the ‘micro’ level is about improving patients’ experience of healthcare by planning and coordinating it from their perspective. Unfortunately, at the moment, research shows that the financial constraints on NHS bodies and local councils are making this kind of ‘integrated care’ hard to achieve. (For example, lack of funding – for instance for social care or district nursing – means that some patients cannot be discharged from hospital when they are ready).
However, ‘integrated care’ has also been adopted by some think tanks and those seeking a greater role for the private sector in health care provision, and they mean something quite different by the term: in this context, ‘integrated care’ is used to justify the radical redesign of health services, ostensibly to make these ‘financially sustainable’. This understanding of ‘integrated care’ puts less emphasis on patients’ needs. Instead it focuses more on integrating organisations and introducing new ways of working, payment systems, and so on that will keep health care systems under tight central control and ensure that they will cut costs in response to underfunding. It is this second meaning of ‘integrated care’ that is being used by bodies like NHS England (NHSE) when introducing its ‘new models of care’.
Ironically the ‘transformation’ that the NHS in England is currently undergoing in the name of integration is actually fragmenting the NHS. It’s making local areas appear responsible for the underfunding from central government and – because of the variation in health need and resources between these areas – will lead to health inequalities and regional differences in health provision.
The idea of ‘integrated care’ in this second sense originates from, or at least has been advanced by, multinational corporations. For example, in 2012, the World Economic Forum – an international organisation that describes itself as “providing a platform for the world’s leading 1,000 companies” – ran a project concerned with the financial sustainability of publicly provided health services, including the NHS. The project team, dominated by senior representatives from multinational corporations, was steered by Simon Stevens (then President of the giant US corporation, UnitedHealth Group, now head of NHSE). The team’s report, co-authored by global consultancy firm McKinsey and Co, offered governments a number of strategies to deal with the problems it identified, such as “the growing burden of chronic disease” and “patients’ raised expectations”. The report’s preferred solution was to lower costs by, for example, introducing new payment systems for organisations to encourage savings, cut services in higher cost settings such as hospitals, and get individuals to provide more ‘self care’. At the same time, the report argued that corporations should be allowed greater access to publicly run health systems like the NHS to provide new products and services while governments cut back on publicly provided care.
A year later, a second ‘sustainability’ WEF project took place, steered by Simon Stevens, among others, and reported again in collaboration with McKinsey and Co. This called for a shift towards ‘integrated care’ systems, such as the Alzira model developed in Spain (see below).
Integrated or accountable care and the NHS
It was shortly after these reports were published (i.e. April 2014) that Simon Stevens was appointed Chief Executive for NHSE (a non-governmental, largely unaccountable body), just six months before it published its Five Year Forward View (5YFV). This plan for the NHS in England echoed many of the WEF’s proposals and argued for the integration of health and social care services.
This ‘integration’ was taken forward by NHSE decreeing that England was to be divided into 44 geographical ‘footprints’, initially called Sustainability and Transformation Plans (STPs). These were later renamed Sustainability and Transformation Partnerships (ST Partnerships) and directed to set up systems in which the budgets of local authorities and local health bodies would be pooled, so enabling the joint commissioning of services.
Oddly, these integration plans fail to acknowledge the very different forms of funding for health and social care. Until now, NHS services have been free at the point of use (except for some services, such as dental care). In contrast, social care is provided on the basis of means testing and user charges. Not surprisingly, many see this integration of health and social care as a step towards introducing means testing and further charges for NHS care, especially at a time of unprecedented cuts and questions from some quarters about the financial sustainability of the NHS.
According to NHSE, ‘integration’ is to be brought about by radical changes to the way care is delivered or what are called ‘new care models’, such as the Multispecialty Community Provider’ (MCP) and ‘Primary and Acute Care Systems’ (PACS) referred to in the 5YFV. These new models of care bring together different services (such as GP, hospital specialist and social care services) within one system in a way that NHSE has said is similar to the Accountable Care Organisations (ACOs) found in countries such as Spain and the US. The form most frequently referred to by NHSE, at least up til 2017, is the Spanish Alzira model.
In Spain, the Alzira model is based on a public/private partnership between local government and a consortium of businesses such as banks, construction firms and a private health insurer. (For more information on the Alzira model, see our page on Accountable Care Organisations.)
In the US, models of accountable care evolved from Health Maintenance Organisations (HMOs). HMOs, run by medical insurance groups, have been notorious for denying patients access to treatment; refusing policies to those with pre-existing conditions; and paying CEOs exorbitant salaries. ACOs were introduced to reduce spending while improving quality measures. The evidence that they do either is not convincing. They also aim to shift risk from payers (e.g. insurance companies) to service providers who are paid to manage outcomes and the health of whole populations rather than services provided.
However, it seems that HSE’s plans to entirely restructure the NHS through new models of care and organisational systems have been poorly thought through. Until recently, NHSE’s ambition has been for ST Partnerships eventually to become full-blown Accountable Care Organisations (ACOs), but because of the complexity of this process, ST Partnerships were to evolve into what were initially called Accountable Care Systems. But the introduction of ACOs met with considerable opposition from campaigners and the House of Commons Health Select Committee, among others, not least because these plans ran counter to existing legislation, were being introduced without adequate public involvement or meaningful consultation, and without Parliamentary scrutiny. There is now a pause in the development of ACOs. And, because ‘accountable care’ has become something of a toxic brand, it is now usually referred to as ‘integrated care’. ACSs are now to be called Integrated Care Systems (ICSs).
ICSs are expected to evolve from ST Partnerships. According to Chris Ham of the Kings Fund, ICSs will bring together public sector organisations in a system that plans and commissions services across a geographical area. Unlike CCGs, they are not statutory but voluntary bodies. In early 2018, there were 10 such ICSs across England. Within these, various providers are coming together in what the Kings Fund refers to as Integrated Care Partnerships to deliver services to more localised communities. These providers include hospitals, community services, mental health services and GPs, but may also involve social care, independent and third sector providers.
These organisational forms will be financed by new capitated payment arrangements, such as a ‘whole population budget’ (a fixed payment to provide specified services for a defined, geographical population, for a set period of time). This type of payment system – especially in the absence of adequate funding, and even with minimum standards in place – provides an incentive for rationing or for raising the threshold at which patients are offered treatment, irrespective of the care needed, in order to minimise costs.
These new ways of commissioning and delivering care also represent a move towards increasing control of local health systems from the centre – e.g. the Treasury, NHSE, NHS England and the Department of Health and Social Security. ST Partnership plans and key appointments need to be approved by NHSE, while the spending across systems like ACOs is tightly controlled by NHSE and NHSI.
There is additional concern that the new structure of the NHS could, in future, facilitate a shift in the fundamental nature of the NHS, away from a public service funded by central government taxation to cover the cost of treating all healthcare need, and towards a privatised system.
For instance, some fear that the draft model contract for ACOs published by NHSE allows for, and may well attract, bids from multinational corporations – in fact, an ACO needs to be set up as a commercial body even though it may consist of, or include NHS providers. The Kings Fund (again Chris Ham) casts doubt on whether multinationals could provide the range of services involved in an ACO, and therefore ACOs will be led by NHS organisations. Others believe that while multinationals are not able to afford to take over the NHS as a whole, once it’s carved up into local systems like ACOs, the NHS could be increasingly privatised in a piecemeal manner. While private companies have sometimes struggled to make enough profit from contracts to provide individual services, budgets available for whole systems like ACOs will be large enough to attract private investors. By becoming a ‘lead provider’ with a single, long-term contract to set up and manage an ACO, private companies can make decisions on the nature and location of services, for example, and sub-contract with other providers as necessary.)
This type of system 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 by imposing charges for some services. (See also our pages on A Long Term Plan and Sustainability.)
In February 2017, the National Audit Office (NAO) produced a report warning that progress with integrating health and social care had, so far, been less successful than imagined; that it had not brought the expected benefits for patients, the NHS or local authorities; and that the aim to integrate health and social care services across England by 2020 was unlikely to be met.
The NAO’s report also found that NHS England’s ambition to save £900 million through introducing new care models may be optimistic. These new 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.
Finally, despite all this talk of integration,
See also our pages on
- Accountable Care Organisations
- Accountable Care Systems (now Integrated Care Systems) and
- implications of ACOs and ICSs).