Health Service Focus

Integrated health: how do the case studies stack up?

NHE’s Seamus McDonnell explores the successes and challenges of different models of care integration currently taking place across the UK.

Integrating healthcare services has been a hot-button issue in the UK for a number of years because of the promise it claims to bring. Integration, to some, means efficiency, fluidity and a joined-up approach to health and care which improves the quality of services without huge increases in cost.

Sustainability and transformation partnerships (STPs) have now become the NHS’s first port of call for local organisations trying to integrate care. While some of these plans have no doubt been successful, most would agree that integration itself is still at an early stage, with a lot of lessons left to learn.

A central theme that does seem consistent across the geographical areas which have successfully implemented a form of integration is the close relationship between health services and local authorities – a relationship which, in a lot of cases, existed before STPs were formed in 2016.

Forming close relationships locally

Northumberland is a good example of this because of the close relationship between Northumberland County Council and its surrounding health and care services, such as Northumbria Health NHS FT and Northumberland CCG.

Daljit Lally, chief executive at the council and one of the executive directors at the trust, attended The King’s Fund’s annual conference in November to explain how the integration of health and care between different organisations in the county had come about.

She spoke of the Care Trust scheme, created in 2000 as an early attempt to integrate health and social care which was later abandoned. Northumberland was one of the pilots for Care Trusts, and Lally said this initial push set the system in place which is still used locally.

“We had a lot of pressure at the time to transform community services, and we took the route between the health services and the council because, for us to meet the needs of our population, it was really important,” she explained.  “I am really pleased we stuck that out now.”

There are still difficulties, with the county going through three distinct changes in political leadership since 2008 and a wide and varied geographical area covering both urban and rural areas.

However, the area does have clear advantages over others: it has a CCG which covers the same geographical boundary to its council, which in turn is unitary, meaning that many of the decisions go through one single body and do not have to be filtered down through a two-tier system of larger county councils and smaller districts or boroughs.

In comparison, in Hackney, central London, there is a more recent history of care integration which was developed from 2013 as a response to long GP waiting times and a rapidly increasing demand for services.

Hackney Council works alongside as many as 10 other major organisations to achieve an integration model ‒ these include three separate trusts, two Healthwatch groups, and the City of London itself.

Cllr Jonathan McShane is cabinet member for health and social care for the authority, as well as taking responsibility for devolution – an important detail as it shows the relationship which has developed between devolution and integration in the area.

During the King’s Fund conference, he explained the path of health integration in Hackney, highlighting the development of a local Leadership Summit in 2014, which worked to submit a devolution paper that was completed in November 2017.

Change over a long period of time

McShane stressed the importance of an extended period of time for the council and health organisations to work towards an effective system.

“Understanding each other’s issues, the challenges we face as a system but also the individual organisations, and the areas where we can best make a difference working together – that can take a long time.”

However, he added that, despite a lack of knowledge concerning the roles and challenges of each individual organisation, there was no “underlying antagonism” in Hackney, which has stood in the way of integration efforts in other areas.

Similarly to Northumbria, Hackney has a CCG which covers roughly the same geographical area as the local authority, but it is part of a two-part governmental system with the council controlling some services and the City of London in charge of others.

On the other hand, the area does benefit from the provision of just one hospital used by the majority of residents, which means services can be more easily coordinated – a situation that is unusual for a London borough.

Working towards health integration has pushed leaders in Hackney to put forward devolution bids proposing that the area become a pilot scheme for future projects. This involved considering a number of options, including moving towards joint commissioning and shared service provision.

The importance of scale

This is a style of integration that has also been seen in Greater Manchester, where devolution has been central to the way organisations approach healthcare.

Jon Rouse, chief officer at Greater Manchester Health and Social Care Partnership (GMHSCP), has been heavily involved in the region’s healthcare integration plans, which have faced different challenges to Northumbria and Hackney – largely because of the scale involved.

There are 2.7 million people under the jurisdiction of GMHSCP, which covers 10 separate councils all ultimately beneath the banner of Greater Manchester Combined Authority.

To deal with the wide area covered by the authority, the health partnership plans to create 10 local care organisations – which bring together providers – as well as to build an integrated commissioning system to integrate health across Greater Manchester.

The organisation was given £6bn by the government along with new regional powers over health and social care policy. Rouse said this has driven the integration of health and social care within the region because it improves the quality that can be provided within available resources.

He also reiterated some very similar points to those raised by McShane and Lally, who both stressed the importance of commitment from all parties involved in order for plans like this to be successful.

On the subject of organisations working together, Rouse said: “Frankly, if your heart isn’t in it you might as well not start because, at the end of the day, that partnership is going to be tested, and probably tested close to destruction.”

This seems to be one of the central tenets running through all three of the integration attempts analysed here, along with a movement towards devolution ‒ which gives organisations the power to make decisions more effectively and a significant timescale of development, allowing the complexities of different systems to be explored.

There are clear differences between each of these areas, however there are similar lessons running through each plan and, overall, it is apparent that integration is going to be essential to improving healthcare in the future.

Top image © Daniel Kay

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