Realising the long-term vision for integrated care
By Integrated Care Journal-
Health is not a series of unrelated transactions. It does not begin and end with the treatment of disease. Our health is defined by each and every facet of our day-to-day lives. Diet, education, transport, housing, the very networks of civil society – each represent an integral puzzle piece to the complex jigsaw of a person’s health.
The significance of these social determinants in influencing our health is widely understood. And yet, there exists an historic division between health and social care in the UK. This division can be traced back to the very inception of the NHS, with the publication of the Beveridge report, the document directly responsible for the development of these two very different systems.
On the one hand we have the NHS: comprehensive; free at the point of use; a major political priority; heavily centralised; bureaucratic; and with a democratic deficit. On the other, we have social care: varied in application; controlled by local authorities; and funded through a range of vehicles, including patient charges, local fees and central Government grants.
Changing patterns of need, resulting from our growing ageing population and increases in the number of people living with long-term conditions, has necessitated that the NHS provides more care in people’s homes and the community. Moreover, it has become increasingly evident that large portions of our healthcare expenditure relate to demands that are predictable and thus lend themselves to prevention or early intervention.
Taken together, these considerations have demonstrated that the efficient delivery of care requires a more integrated model of support that breaks down the barriers between health and social care. To address the social determinants of health, as well as manifestations of ill-health, the NHS must engage more fully with the full range of organisations that serve each local community. Doing so will bring together all aspects of health and social care and work as one united ecosystem, with the common purpose of improving health outcomes.
Regrettably, institutions of UK public decision-making have demonstrated an extraordinary maladjustment to taking advantage of opportunities for integrated interventions. Repeated reorganisations of the NHS have discouraged these in favour of seeking internal solutions. Moreover, silo-thinking has prevented NHS organisations from maximising opportunities for external partnerships, effectively eliminating consideration of the wider health policy context.
Integrated Care Systems
In 2019, the NHS Long-Term Plan (LTP) prescribed integrated care systems (ICSs) as the main mechanism for achieving this shift towards integrated care to improve population health. ICSs offer a more integrated model of support by bringing together hospital and community-based, physical and mental health, and health and social care services into one unified ecosystem. Such a model has the potential to drive improvement in population health by reaching beyond the NHS focus of acute care to include the local authority focus on the social determinants of health that drive longer-term health outcomes.
Governance and accountability
The LTP outlined a number of core requirement for ICSs, including the establishment of a partnership board comprised of representatives from across the system, but neglected to provide a blueprint for their size or structure. As such, ICSs have no legislative basis and thus remain voluntary partnerships with no formal authority or accountabilities at present.
However, the LTP does state that integration will be supported by a ‘duty to collaborate’ on providers and commissioners, and does propose a list of legislative changes to catalyse the process of their creation, such as a mechanism for joint decision-making between providers and commissioners.
Previous proposals for centralised models of integrated care run the risk of losing the benefits of local government insight and services. Moreover, such models are in danger of imposing top-down, one-size-fits-all instructions that fail to take into account local circumstances and views. This would diminish the opportunities for personalised care, making it more difficult to meet the unique needs of local populations.
As such, many have argued that ICS bodies should remain decentralised in order to ensure accountability to the authorities, and ultimately the citizens, in their locality. This will require permissive statutory changes that enshrine ICSs in legislation, while also allowing local areas the flexibility to shape their work around their circumstances.
One of the main proposals of the LTP is an explicit role for local government in decisions made by an ICS. This is essential because local government is responsible for social care and represents a powerful voice in both service authority and the community. However, this dynamic of joint decision-making between the NHS and local government has proved difficult to establish as the NHS is averse to external partnerships and local authorities remain reluctant to spending more of their own funds.
It is crucial that we move past the current transactional relationship and build a partnership between these bodies that focuses on a common purpose. Both bodies are funded by the taxpayer. Both share the common goal of delivering better life chances to the people within their community. We need to develop an ICS model where funding is best applied to delivering this outcome, regardless of whether services are delivered by the NHS, a local authority, within the third sector or by an individual. This could open the door to greater emphasis on prevention and support, and reduced reliance on acute care and crisis management.
Modern data tools allow policymakers to identify patterns and trends associated with the causes of diseases such as diabetes, dementia and cancer, but current structures are ill-designed and ill-equipped to take advantage of these opportunities. Technology creates networks that allow linkages between different actions to be analysed and understood. The challenge for health and care service providers is to redesign their services in ways that allow them to respond effectively to the connections digital technology provides. Data must sit at the heart of effective ICSs, but it has too often been held in silos, meaning that clinicians and care professionals do not have easy access to all the information that could be useful in caring for their patients and service users.
In order to address the social determinants of health, as well as manifestations of ill-health, the NHS will need to engage more fully with the organisations that serve each community to bring together all aspects of health and social care, and work as one united ecosystem with the common purpose of improving health outcomes.
Successful ICSs will not simply represent an integration of bureaucracies – they will unite services to provide holistic care services to individuals. This will require the integration of hospitals with third-sector operators – such as the housing associations, drug and alcohol services, and law enforcement agencies – so that ICSs can deliver person-centred support to individuals when and where it is needed.
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