Integrated care… getting rid of bad care from the bottom up?
13 June 2018
Policy & health systems
The House of Commons Health and Social Care Committee published its Integrated Care Report on 11 June. Tweets from the launch quote Don Redding, Director of Policy at National Voices saying; ‘Integration is not about privatization….it’s about getting rid of bad care’. I’m currently writing up my doctoral research, which explores the connections between policy priorities and individual experiences of integrated care, so was interested to see what this latest report adds to the discourse of integrated care, which I analysed last year.
The latest Select Committee report accepts that integrated care will not necessarily save money. This represents quite a shift from the Health Select Committee of 2013 which saw integrated care as the policy solution that would both save money and improve the quality of services, stating; ‘Only through a new commitment to integration of the different strands of health and social care can the economic requirements of the Nicholson challenge and the broader objectives of enhancing the quality of health and care services be met’. This is a welcome shift for those of us interested in evidence-based health care (and policy), acknowledging as it does the weight of research evidence on the effects of integrated care.The most recently published systematic review of the effects of integration by Baxter et al., 2018 concludes, yet again, that there is unclear evidence that integrated care reduces service costs.
It’s also of interest to see the concerns such as those raised by Keep Our NHS Public about the privatisation of the NHS acknowledged so directly, likewise the open discussion of fears of ‘Americanisation’ related to the potential introduction of Accountable Care Organisations in England. I doubt that these fears will be quelled by comments in the report about privatisation being unlikely because of the lack of profit in providing integrated care. However, even this framing of the Americanisation of UK health policy as a potential threat represents a shift in the discourse of efficiency in healthcare in the UK that has been heavily influenced by North American health policy since the introduction of the Evercare model of case management in the UK in 2003 (Gravelle et al., 2007). Perhaps this reflects wider reservations about the special relationship.
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A critical new twist in the tale of integrated care is the discussion of changing the law to remove the additional barriers to collaboration erected by the 2012 Health and Social Care Act. Previous discussions of integrated care have circled around the disruptive option of further reform. New primary legislation will be needed, concludes this Committee, but, well, Brexit. There won’t be time for much else to happen in Parliament.
And what remains the same…
Instead there is an expectation that workarounds continue, at organisational as well as at individual level. This is how integrated care is actually delivered to patients, at what is often termed the ‘micro’ level. Patients, carers, and professionals do continual, effortful work to provide, access and coordinate care around many different kinds of obstacles. Here, there is little change in the discourse. What patients or service users want from integrated care – person-centred coordinated care - has been clearly stated before, yet achieving (and measuring progress towards) this remains elusive, as this report notes. Organisational changes do not necessarily result in improved experiences for patients and service-users, yet we see another trend perpetuated; the continued commitment to market-derived mechanisms to achieve integrated care by organisational means. Although this report represents a certain amount of rolling back of the internal market, and in particular the role of financial competition in achieving integration, the process of contracting remains central to recommendations of how to achieve integrated care. The Accountable Care Organisation (ACO) contract seems to offer the way towards more integrated systems by creating a mechanism for a single body to be funded, and held accountable, for the provision of services for a designated population.Yet, a contract does not, in itself, create an organisation. For a single organisation to emerge from the complex patterning of primary care and general practice, social care and NHS trust provision that exists in any English locality would be radical change indeed, given the history and politics that have shaped these different types of organisation.
The most disappointing aspect of the continuity between this report and previous policy is the continuing lack of commitment to address the financial deficits experienced by the NHS and local government. Public expenditure continues to be sacrificed in the name of economic growth, despite the acknowledgement of the select committee that a new settlement for health and social care is needed. The report is clear-sighted that integrated care is no substitute for adequate funding. Yet despite criticisms of NHS bodies for the lack of engagement in Sustainability and Transformation Plans (STPs) that aim to reduce hospital activity (and for the alphabet spaghetti of confusing acronyms), the underlying financial imperatives that drove these plans remain ominously present for NHS managers trying to steer their budgets through the emerging landscape of Integrated Care Partnerships. Bottom-up changes and collaborative workarounds will not fix shortfalls in care provision without sufficient funding.
To conclude, this report adds a more nuanced and realistic understanding of what integrated care can achieve to the existing discourse, recognising concerns about privatisation and lack of engagement, and the need for both additional investment and new legislation. However, it also perpetuates expectations that organisational mechanisms, such as the ACO contract, will achieve integrated care, leaving patients, carers and professionals to continue to find workarounds in the meantime.
- Baxter, S., Johnson, M., Chambers, D., Sutton, A., Goyder, E. and Booth, A. (2018) 'The effects of integrated care: a systematic review of UK and international evidence', BMC Health Services Research, 18(1), pp. 350.
- Gravelle, H., Dusheiko, M., Sheaff, R., Sargent, P., Boaden, R., Pickard, S., Parker, S. and Roland, M. (2007) 'Impact of case management ( Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data', BMJ, 334(7583), pp. 31.
- The Committee Office, H. o. C., Health Committee (2013) House of Commons - Health Committee - Eleventh Report: Public expenditure on health and care services.
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Nick Fahy is a senior researcher and consultant in health policy and systems at the University of Oxford. He also blogs about health and Brexit at www.nickfahy.org