Michael Macdonnell

Michael is responsible for integrating health systems across the English NHS that join up primary care and hospitals, mental and physical health care, NHS and social services. Previously, he was strategy director at NHS England, senior fellow at the Institute for Global Health Innovation, Imperial College London and advisor at the prime minister's delivery unit under Tony Blair. 

The NHS just turned 70. At its inception, Aneurin Bevan predicted that the health service 'must always be changing, growing and evolving' so that 'it must always appear to be inadequate'. Since then the NHS has pioneered game-changing innovations like MRI scanners, IVF and a revolution in mental health services, to name but a few.

As Bevan said, the NHS will need to keep changing, not least because what people need is changing too. Today there are half a million more people aged over 75 than there were in 2010, and there will be 2 million more in ten years’ time. There are already 15 million people with chronic diseases, many of whom live with multiple conditions. People with long-term conditions now account for about 50% of all GP appointments, 64% of all outpatient appointments and over 70% of all inpatient bed days.

Changing the model

Seventy years ago, hospital wards might have been full of people with tuberculosis, other infectious diseases and traumatic injuries. Unlike these, chronic conditions such as depression or hypertension aren’t cured by a trip to the hospital, they are long-term, requiring continuity of care and joined up services that help people manage their own health. Preventing or managing these conditions requires services to get upstream, ultimately supporting people to alter the unhealthy behaviours that cause or exacerbate them.

This is what integrated care means, the NHS and local government collaborating to provide joined up services that are 'anticipatory', with the aim of preventing ill health or unnecessary hospitalisation.

The 14 ICSs across the country are beginning to do just this. Systems like Frimley and the Fylde Coast are reconnecting GPs and consultants, joining up teams working in surgeries and hospitals, resulting in reduced referrals and non-elective admissions. In Buckinghamshire, GPs collaborate to prevent avoidable hospitalisation, re-investing funds from QOF to support proactive care. To further hasten the integration of primary and community care, providers and commissioners in Dorset collectively took the decision to invest £6m recurrently, re-allocating system funds to support a new model of care. In the vanguard systems, between 2014/15 and 2017/18, growth in emergency admissions has been held to an average of 0.9%-2.6% per person whilst in the rest of country they have increased by 6.3%.

Preventing or managing these conditions requires services to get upstream, ultimately supporting people to alter the unhealthy behaviours that cause or exacerbate them.

   

A common architecture

We have learned from these 14 systems that integrated care has a common ‘architecture’. At the neighbourhood level, primary care networks collaborate to improve general practice resilience, share staff and assets and provide proactive, multidisciplinary care to populations of about 50,000. At the place or locality level, often coterminous with district/borough councils, acute providers integrate their services with primary care networks, local government and mental health around those patients that could be kept out of hospital and empowered to look after themselves better. Systems, serving populations of about 1 million or more, take overall responsibility for improving services within their share of NHS resources. They foster 'horizontal' collaboration between providers and shape the provider landscape. They develop system strategic and operational plans, including for infrastructure like digital and estates.

Providers must be at the heart of this work. Integrated care is not about structures, the wiring behind the scenes or even money flows.

   

The role of providers

Providers must be at the heart of this work. Integrated care is not about structures, the wiring behind the scenes or even money flows. That’s why, although systems are important, the action is really in neighbourhoods and places. This is where the hard but exciting work is done to (re)connect clinical teams across traditional organisational and professional boundaries. Neighbourhoods and places are where providers, GPs and social services collaborate to develop proactive services for those people most at risk of getting acutely ill.

ICSs are the direction of travel for the NHS. Their development is in response to ageing and epidemiological trends common across all advanced economies. The long term plan for the NHS, which will be published in the autumn, will set out how we intend to catalyse them across the country, supercharging their spread. These systems are the opportunity and the vehicle for providers to be at the forefront of evolving a health service fit for the next 70 years.