Health and social care committee submission: Integrated care: organisations, partnerships and systems inquiry
Key messages from the submission include:
- Context: In the face of significantly increasing levels of demand and acuity, with funding levels not keeping pace, the need for health and care services to transform is widely recognised both locally and nationally. Trust leaders support collaborative working, the idea of system-based planning and the vision outlined in the Five year forward view of new ways of providing care. As the NHS moves from a focus on individual NHS institutions to integrated local health and care systems, it is right that the most viable vehicles for achieving this – sustainability and transformation partnerships (STPs) and accountable care models – are properly scrutinised, locally and nationally.
- Effective integration: The NHS and social care are being asked to deliver a breadth and scale of transformation that many other international health systems have taken at least a decade to achieve. It remains early days in their development and, given the complexity of the task, it is understandable that the progress made by each footprint to date is variable. In our recent conversations with trusts, a number of key factors contributing to the progress of STPs have become clear. Above all, local leaders from STP areas where plans are more advanced uniformly point to a history of trusted partnership working as the foundation for their achievements and future aspirations.
- Progress Dashboard: The ratings give a useful broad indication of progress, but should be treated with a degree of caution, both in their interpretation and their application. In particular, the use of performance figures underlines the continuing tension between sustainability and transformation expectations, with no current measures looking directly at the degree of change against plan and integration achieved. The dashboard also highlights the issue of how the regulators balance oversight of health systems with individual institutions. Regardless of their rating, the national bodies should support all STPs, not just those that are advanced or behind, and avoid further polarisation of the performance of the system. We need to consider both how we support all STP footprints and how we manage the reality that it may be impossible for some areas to come to fruition and make sufficient progress to deliver the necessary change.
- Deliverability of STP plans: Despite the strength of the vision and the degree of agreement behind STPs, the NHS risks being pulled away from collaboration through pressure on financial and staffing resources. There is also a lack of consistent focus and priorities set out by the NHS national bodies, which is proving challenging, and a continuing tension over whether short-term financial sustainability or long-term strategic transformation is the priority for STPs in the eyes of the NHS national bodies. The considerable financial and operational investment is further under-acknowledged: local areas will need to ensure a managed transition (most likely through a period of double running) to ensure new models are proven. While STPs and improved care configuration are likely to contribute to better performance standards, this will only be over the long-term. They are not a short-term route to meeting the NHS constitutional standards.
- Credibility and realism of STP plans: The changes in emphasis around sustainability versus transformation mean that the STP plans are similarly variable in whether they were predominantly based on either (1) on the expected funding envelope, and tailored to fit, or (2) the ambition for future health and care services first and foremost, and then adapted to the expected available funding. In reviewing STP plans, we would encourage consideration of issues including: how bed capacity is redistributed through the system, the investment required and efficiencies expected, the leadership and workforce implications, and the intended timescales.
- Delivery of care by accountable care systems (ACSs): Accountable care models – within the England health and care system – bring together a variety of provider organisations, including primary care, to plan for and meet the care needs for a defined population within a set budget to an agreed level of quality. While an ACS is not necessarily the same as an STP – not least as one STP footprint may ultimately encompass multiple ACSs – ACSs and STPs are pursuing similar objectives through similar means.
- Governance, management and leadership: Neither STPs nor ACSs are statutory bodies – they derive their legitimacy from their component organisations, and it is largely this fact that is driving the complexity around their development. As STPs and accountable care models move to becoming delivery vehicles, it will be important to ask: are internal governance arrangements suitably robust; are the structures in place for each STP legal; are accountability structures clear; and how will the oversight regime operate?
- Legislative, policy and other barriers: Competition as the key driver of improvement in the system is underpinned in legislation by the Health and Social Care Act 2012. The move towards locally-based collaboration is therefore a significant shift in national policy. While the current legal frameworks do not prevent partnership working and integration in different forms, this makes for a complex environment for trusts, and their partners, to navigate. There are also a number of policy areas which need to be addressed in taking STPs and accountable care models forward. First and foremost, there needs to be far greater clarity and discipline over what STPs are intended to deliver. Additional issues include ensuring support for all STPs, realistic expectations, regulatory and financial alignment, and clarity over data sharing.
- Public engagement: Reconfiguring services in health and care has historically been highly controversial. Despite the high-level parameters for public engagement within the Next steps, this has arguably not been robustly promoted by the arm’s length bodies. Overcoming the concerns that have arisen as a result will take considerable time and effort, but it is crucial to do so – otherwise the progress made in improving patient care through better joined up services will be jeopardised.