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Progress on integrated care

Don Redding, director of policy at National Voices, the coalition of health and care charities, looks at the challenges facing integrated care in the NHS.

This year’s conference of the International Foundation for Integrated Care (IFIC16) in Barcelona attracted over 1,000 delegates and participants. Shortly afterwards, the World Health Assembly adopted a global framework on ‘integrated people-centred health services’ developed by the WHO, and an alliance of organisations created a European call for action to implement the framework at EU level. 

It was, in short, the year that ‘integrated care’ became a genuine international movement. Among other things this laid to rest many of the befuddling definitional problems that have plagued efforts to integrate services over previous decades. 

At the heart of the global definition now sits the goal of being ‘people-centred’. European Patients Forum chair Nicola Bedlington has summarised this as “identifying what matters to a patient and arranging care around this, with the patient and family as full partners”. 

National Voices takes great pride that the definitional Narrative that it created with Think Local Act Personal (TLAP), NHS England, the Local Government Association and other partners in 2013 has helped shape this international framework, and has been used as an inspiration in countries including Spain, Sweden, Ireland and Australia. 

As I noted in a plenary address for IFIC16, there is a long way to achieve the ‘person-centred’ goals in the Narrative. Systems tend too easily to default to seeing that person as a passive object, in the middle of a system where the furniture has been moved around into a new configuration. 

Ever-changing goals a cause for concern’ 

But here in England there is additional cause for concern. The ever-changing goals of health reform, churn of leadership, and loss of institutional memory have already begun to dilute the strength of purpose that existed only three years ago, when all the national system leading bodies in health and care signed a ‘shared commitment’ with the Narrative at the centre. Of the signatories from those 14 bodies, nine are no longer in their role. Two of the bodies have merged. Most have had budget cuts.  

The DH itself has been hollowed out and no longer seems to remember the work or to take close interest in the major programmes of work that resulted, particularly the 25 integration pioneers. 

At NHS England, following a change at the top, the FYFV was launched and is now the single compelling force driving ‘transformation’. The pioneers were quickly eclipsed by (or cannily morphed into) the vanguards, 50 local sites prototyping new models of care. 

Here we start to cross our fingers somewhat nervously. Let’s be clear: National Voices helped shape the Forward View, especially its ambition to work in new ways with people and communities. Through the People and Communities Board we helped develop the six principles for engaging people and communities that the vanguards are expected to implement, and which include the principle that care should be person-centred and co-ordinated. 

So we support the direction of travel, and welcome the aspiration for new models of primary and community care quickly to spread to cover at least half the population. Yet these shifts have brought a change of language and emphasis. Integration becomes more implicit than explicit. Tackling the three ‘gaps’ of prevention, care quality and sustainability has taken over. 

A new planning system has been invented, via the 44 sub-regional ‘footprints’ that must produce approved STPs for the next two financial years. But the funds that could have supported that transformation are now eaten up in so-called ‘sustainability’ – that is, plugging the existing and unprecedented deficits in acute trusts. 

Meanwhile in day-to-day business inside the commissioning system, any new plan, programme or initiative is ruthlessly interrogated for its contribution to cost savings, either immediate or by ‘bending the demand curve’ in the near future. 

The new approaches to person- and community-centred care and support can’t meet those demands. Their evidence base is promising, but limited – that must be the case with new things! 

National Voices has confidence that over time, these approaches will generate greater value and the most appropriate use of resources; that’s not the same as promising to ‘save money’. We cannot know their overall effect on sustainability until they have been tried in mainstream care design, at scale, over time. 

To judge whether the key elements of the FYFV succeed, we will need new outcomes: focused on overall health and wellbeing; reflecting ‘what matters most’ to people; and consensually covering the combined efforts of the formal health and social care systems and the voluntary and community sector. 

But the governing metrics for so-called transformation and integration are those for secondary care resource use: admissions, readmissions, lengths of stay, delayed discharge. On any given day these easily trump such measly indicators as the quality of life and death, or being supported to self manage effectively. 

Has the historical moment for the primacy of ‘people-centred integrated health services’ arrived just too late? Will ‘transformation’ expire in its cradle while all attention is on ‘efficiencies’? As ever, National Voices, the People and Communities Board and the VCSE sector more widely are working to ensure the answer to these questions is no.

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