Delivering integration at pace and scale

Integration of health and care is now the key objective of health reform. With healthcare needs changing because of an ageing population and the growing prevalence of chronic conditions such as diabetes, many experts and NHS leaders have advocated joining up health and care services. In recent months NHS England, the Government and the Opposition have announced new initiatives and proposals to deliver integration at pace and scale. While policymakers and politicians appear to be united in the direction in travel there is still debate on how to get there and profound barriers to change. In October 2013 Reform partnered with Novo Nordisk to explore how policymakers can facilitate integration that benefits patients. The seminar was led by Bill McCarthy, National Director of Policy at NHS England.

Relationships matter

Integration has been on the agenda for years but there is still debate on what good integration looks like. There is greater recognition that integration is not about organisational form but about care that patient-centred, coordinated, holistic and tailored to individual needs. To deliver services that meet this ambition creating “transactional” coordination between organisations is insufficient; it is relationships that matter. Not just relationships between different kinds of clinicians and NHS providers and other services but critically the relationship between the patient and their caregivers. A more integrated model of care would build the capabilities of those patients most at risk to allow them to stay out of hospital for longer. This is about building “trust” in community services through harnessing a range of providers such as housing, volunteer organisations and families to improve health and not simply treatment. But at the same time integration cannot be achieved through making hospitals “the enemy”. In some health economies acute providers will be best placed to develop the capacity of community care and create better pathways

A model of change

Such changes depend on harnessing local creativity. There is also a crucial role for NHS leaders in setting out a national vision. Getting the right balance of the national and the local has always presented a challenge for policymakers. Already the £3.8 billion Integration Transformation Fund and the 14 pioneer projects have been a catalyst for change in many areas. Raising the awareness of the challenge of particular disease areas, such as diabetes, could also help unlock barriers and stimulate local efforts. National leaders can also focus local leaders on the “quick wins” such as reducing average length of stay for non-elective admissions, or focusing on patients with both mental and physical health needs. However national policies and pilot projects cannot become an excuse for inaction. Too often in the past local leaders have either looked towards the centre for instruction or to pilot sites to take the lead. On other occasions NHS organisations have focused on a few key initiatives such as risk stratification without linking up the different strands of reform. Integration has to be everywhere and all local leaders need to take the initiative and ownership of change.

A role for the centre

National policymakers have a critical role in tackling the barriers to change such as workforce reform. Integration requires harnessing more local assets than just the medical workforce, it was also felt that challenging and changing the medical profession will be needed. Doctors are still largely trained to deliver acute care in hospital settings and a shift in emphasis to chronic care and community settings is needed. Enabling local leaders to manage and commission primary care is also essential if the NHS is to deliver truly integrated care that meets the needs of patients. Standardisation of outcome measures and metrics can also stimulate local innovation. Other challenges such as developing leaders that can drive through change and supporting the “laggards” may also require a national response.

Unlocking the incentives

Currently the tariff system continues to reward isolated activities and not joined up packages of care. In many cases progress towards making services more integrated has been due to local leaders innovating with the payment system. Yet while Monitor and NHS England have recently proposed rules to allow more local experiments, some have argued the system is still too “forbidding”. This reveals the tension within the whole system between short term sustainability and long term transformation. Health and care leaders spend half their day improving services within the system and the other half looking for opportunities to transform it. Whilst there is increasingly a shared vision to achieve change, even the most visionary leaders will find it hard to take bold steps to transform their model of care if it risks financial viability in the short term. Balancing these competing objectives remains an ongoing challenge for policymakers.