The King's Fund
Chris took up his post as chief executive in 2010. He was the director of the strategy unit at the Department of Health between 2000 and 2004 and is an honorary fellow of the Royal College of Physicians of London and the Royal College of General Practitioners. In 2018, Chris Ham received a knighthood in the Queen’s birthday honours list for services to health policy and management.
The case for integrating care around the needs of patients, service users and populations is compelling. It is underpinned by the ageing population and changing disease burden, meaning that more people have complex needs that bring them into contact with a variety of health and social care professionals. A disjointed response to these needs is unlikely to deliver the best possible outcomes, which is why I’ve advocated a shift from fragmented to integrated care for over 20 years.
My views have been shaped by the opportunity to visit and learn from integrated care systems in different countries. Kaiser Permanente in the United States was one of the first, followed by Jonkoping County Council in Sweden and Canterbury District Health Board in New Zealand, to name but three examples. I’ve also been influenced by my work in different areas of England, including Torbay in the 2000s and more recently areas involved in developing new care models following the Five year forward view.
None of these systems are perfect but in different ways they illustrate why integrated care brings benefits. The biggest potential gains are better outcomes and patient experience, but also important are fewer handoffs and delays. Integration helps to reduce demand for hospital and residential care by responding to people’s needs in their own homes and the community. Integrated care won’t reduce how much we spend on the NHS but it should enable resources to be used more effectively.
A disjointed response to these needs is unlikely to deliver the best possible outcomes, which is why I’ve advocated a shift from fragmented to integrated care for over 20 years.
What’s happening in England?
I’ve been encouraged by the work done in the new care models programme and also in the ICSs in England. The tide has turned away from competition towards collaboration, with different areas being given permission to test how to join up care for their populations. Slowly but surely, a focus on places and populations is replacing the emphasis on organisations.
All ICSs have put time into relationship building and are beginning to reap the rewards. This is exemplified by the experience of Dorset and Surrey Heartlands where, at the end of last year, NHS organisations supported each other to hit their control totals in order to maximize the financial benefits to the system of the sustainability and transformation fund. Building collaborative relationships has been easier in some areas than others and has been facilitated by continuity of leadership and the willingness of organisational leaders to leave competitive behaviours behind.
Many of the most positive developments in ICSs are happening in neighbourhoods through the creation of integrated teams serving populations of between 30,000 and 50,000. Frimley is a good example and it has begun to bend the demand curve for hospital care by delivering more care in the community. Parts of Nottingham and Nottinghamshire are seeing similar benefits as the investment made in new care models helps to reduce use of hospitals in some of its places.
A common challenge is to support work in places while also developing leadership and capability to work across the whole system.
Good examples of place-based integration are Salford and Morecambe Bay, which were involved in the primary and acute care systems vanguards programme. Both are well ahead in the development of partnerships linking acute hospitals, community services, adult social care and increasingly general practices. Local authorities often have a strong identity with places, as in the Bedfordshire, Luton and Milton Keynes ICS where there are four places across the footprint.
A common challenge is to support work in places while also developing leadership and capability to work across the whole system. This has involved identifying leaders and senior staff from partner organisations to do this work and to put in place appropriate governance arrangements. ICS leaders come from a variety of backgrounds including commissioner and provider roles in the NHS and local government. All are learning what it means to be a system leader on the job.
Some ICSs are working to improve specialist services. In South Yorkshire and Bassetlaw this involves a review of how these services are delivered to a population of 1.6 million, with the aim of improving patient safety and the quality of care in acute hospitals. Dorset is also in the late stages of a review of specialist services in Bournemouth and Poole hospitals which, subject to the outcome of a legal challenge, will result in Bournemouth becoming the emergency hospital and Poole the elective care centre.
Greater Manchester had a head start on other areas as a result of its devolution deal with the government. It also benefited from receipt of £450m in transformation funding over five years. The ten areas that comprise the ICS are putting in place integrated care partnerships, in places like Oldham and Bolton, within a system-wide framework, focused on improving population health and tackling inequalities. Local authorities are key partners across the conurbation.
ICS leaders come from a variety of backgrounds including commissioner and provider roles in the NHS and local government. All are learning what it means to be a system leader on the job.
Greater Manchester illustrates how ICSs are beginning to take control of performance challenges in their areas. When Pennine Acute Hospitals NHS Trust was rated 'inadequate' by Care Quality Commission (CQC), it was agreed that support would be provided by Salford Royal and Manchester University NHS Foundation Trusts rather than through external intervention. This work is being overseen by the Greater Manchester improvement board with involvement of both commissioners and regulators. Pennine Acute’s rating has been upgraded to ‘requires improvement’ as a result of the intensive clinical and managerial support it has received from its neighbours.
Barriers to progress
Many barriers to progress remain, including the provisions of the Health and Social Care Act 2012, which was drafted primarily to promote competition and which will need to be amended to align with what is now happening. The behaviours of regulators may also reinforce the focus on organisations and in so doing make it more difficult for systems to work effectively. Moves to merge the work of NHS England and NHS Improvement in seven regions may help to align the work of the regulators but leaves open the question of how these new regions will relate to ICSs.
It is important to recognise that ICSs have no basis in law and are entirely dependent on the willingness of the organisations involved to work together. NHS trusts and CCGs have their own statutory duties and members of their boards may need reassurance that these duties are not being compromised by ICSs. Local authorities are fully engaged partners in some systems and on the margins in others, often because of a perception that ICSs are an NHS invention that was not designed with local government in mind. Different accountabilities in the NHS and local government may also cause tension.
Concerns that integrated care may lead to greater private sector involvement have also hindered progress. These concerns arose through the use of the terms 'accountable care organisation' and 'accountable care system' by NHS England to describe what was happening, with connotations of healthcare in the United States where these terms originated. Two judicial reviews (now rejected by the courts) have challenged proposals to develop accountable care and have delayed plans to use a new contract in Dudley and the city of Manchester.
It is important to recognise that ICSs have no basis in law and are entirely dependent on the willingness of the organisations involved to work together. NHS trusts and CCGs have their own statutory duties and members of their boards may need reassurance that these duties are not being compromised by ICSs.
Worries about privatisation have not been helped by the lack of a clear narrative that explains why integrated care matters. Most of the work underway involves public service partnerships rather than the private sector, and starts by asking how to improve the experience of patients and service users by using staff and other resources differently. More needs to be done to communicate this and to share examples of how integrated care is already bringing benefits.
Another barrier is the pressure on organisational and clinical leaders in sustaining existing services while also investing in new ways of working. The care models established under the vanguard programme received some additional funding to support their work and this was valuable in releasing the time of the staff involved and backfilling their commitments. The further development of ICSs would also benefit from extra resources and staff who can commit fully to their work rather than having to juggle multiple demands.
The prime minister’s announcement of a five-year funding settlement for the NHS creates an opportunity to take forward the work of ICSs and to put more in place, as STPs demonstrate their readiness to move in this direction. The government and NHS leaders are now working on a plan for how the additional funding will be used and the indications from former health and social care secretary, Jeremy Hunt, and NHS England chief executive, Simon Stevens, are that a commitment to integrated care will be at the heart of the plan. It is essential that some of the new funding is earmarked to support integrated care rather than being used to pay off deficits.
There is learning here from the vanguards, who received only a small proportion of the additional funding that had been promised as most of the monies were diverted into managing deficits. As the National Audit Office has pointed out, this meant that progress was slower than might have been the case had funding for transformation been protected. I’ve become more convinced that transformation holds the key to sustainability but it will only happen at scale and pace if it is properly resourced.
Work being undertaken in Wigan offers tangible evidence of the benefits of transformation. Under the leadership of Wigan Council, the Healthier Wigan Partnership has started to fundamentally change relationships between public services and the people they serve. The partnership emphasises the assets of communities rather than their deficits and aims to do things 'with' people and not 'to' them. Council staff have been trained to have 'different conversations' with people by asking what matters to them and listening to their concerns.
New care models, some STPs and ICSs are showing the way and patients and populations will see the results in improved outcomes and experiences, and the provision of more care in people’s homes and closer to home. It’s a prize worth fighting for.
Like other local authorities, Wigan has had to make deep cuts in its spending at a time of austerity. It has done so not by 'salami slicing' but rethinking how it can best meet the needs of the population, for example by disinvesting in some services provided by the council and increasing investment in community groups. The focus is on prevention and early intervention, with the aim of reducing demand rather than managing demand.
Over a decade, population health outcomes have improved, council taxes have been kept low, and the council is financially stable. Wigan’s work is underpinned by a deal with the public setting out what the council will do and what it expects of people in return. Learning from this experience, we’ve argued that the NHS should develop a new deal with the public, setting out people’s rights and responsibilities, and should do much more to harness the energy of communities to enable people to take more control of their health and wellbeing.
The health and social care committee has recommended that the law should be amended to align what is now happening in STPs and ICSs with the statutory framework. I agree with the committee that this is best done by asking leaders in the NHS and partner organisations to propose changes, rather than embarking on another damaging top-down reorganisation. In the meantime, it’s clear that progress is possible where leaders have been able to rise above organisational concerns and work to improve health and care for the populations they serve.
Having worked with ICSs around England and observed how they are developing, I’ve described them as 'nascent and fragile'. Impatience on the part of national leaders and others to see rapid results is understandable given the pressures on the NHS and social care but ICSs need time to grow and mature if they are to flourish. Time invested now in building relationships and trust will repay handsomely in future if these leaders demonstrate the constancy of purpose that has often been lacking.
To return to the starting point, integrated care is not a panacea but it does offer the best hope for the NHS to improve health and care to meet changing population needs. The future of the NHS will be secured by working differently, not by asking staff to work harder. New care models, some STPs and ICSs are showing the way and patients and populations will see the results in improved outcomes and experiences, and the provision of more care in people’s homes and closer to home. It’s a prize worth fighting for.