Today marks the biggest legislative restructure of the English NHS for a decade, as integrated care boards (ICBs) take statutory control over a budget of tens of billions of pounds. There will be smatterings of applause in board rooms across the country, and Whitehall will feel that the reforms it spent months passing through parliament are now on track.
But we’ve been here before. This attempt at legally enshrining the integrated boards already underway for years is the latest in a long series of attempts across all the UK’s countries to try to make health and care services work together better. For decades, policy-makers have attempted to bring closer together the planning, commissioning and delivery of health and social care to reduce unnecessary fragmentation within and across services, and support people to live more healthy and independent lives. Many of the previous efforts underline how difficult it is to define and make progress. But what can we learn from the past to set us up better for the future?
Money doesn’t move easily
A persistent obstacle to successful integration is that funding has rarely flowed away from hospitals as has been anticipated. In Scotland and Northern Ireland, where joint structures have been longstanding, pressures in hospital services coupled with competing financial priorities have limited the extent to which funds earmarked for integrated pathways have moved to community health and social care.
Discharging people from hospital is one area where a disparity in funds between hospitals and other services can cause major problems. Across the UK, discharging people in a timely manner and to the right place continues to be a major problem, and depends on the smooth running of community hospitals, care homes, and domiciliary care. Evaluations of discharge models have highlighted that uncertainty around funding often undermine progress made in working together. Successfully agreeing which parts of the system are responsible for different discharge pathways and – crucially – who funds them will be a key test of ICSs in England over the coming months.
The discharge challenge partly reflects how difficult it is to get health and social care working together given their divides and differences, even with pooled roles.
Experiences in Scotland suggest that integrating all health and care services into one statutory structure and pooled budgets was not enough to overcome the deeply embedded challenges of working together. Scotland recently announced it will be replacing its integration authorities, which bear a strong resemblance to England’s imminent ICBs, with new local care boards that will potentially have much less organisational crossover with the acute sector. Instead these boards will bring together community health and social care, and will be funded by, and directly accountable to, Scottish ministers. It is hoped that these new arrangements will overcome some of the problems seen in moving funding.
Designed by committee
Slow progress with integration also raises the question of whether structures really change the culture and behaviours which actually determine how services work together. There has been a consistent tendency in UK policy to create new joint committees and governance arrangements across health and social care in hopes that more collaborative service delivery would naturally follow. While these have looked different in each country of the UK, they have been insufficient to address the culture, norms, systems and processes needed to support integrated ways of working and fundamentally change the way services operate.
Even where integrated care systems have been legal entities, as is the case in Scotland, Wales and Northern Ireland, having a legal duty to collaborate has not in itself led to effective collaboration. This instead relies on having sufficient resources, incentives, regulatory and outcomes frameworks, and consistent leadership and cultures across health and social care – which policy has so far failed to achieve in each country of the UK, and which cannot easily be legislated for.
To be fair, the Department of Health and Social Care and NHS England have recognised that another organisational reconfiguration was never intended to solve all the barriers that make integration difficult. Instead, they have been emphasised as a continuation of integrated care reforms that came before it, and an attempt to remove some of the residual financial and legal hurdles to partnership working. But if real progress on integration is to happen, policy-makers must recognise that decisions and behaviours in health and care are shaped by much deeper factors than committees and organisational diagrams.
What is integration meant to achieve, and how can we tell if it does?
Experience across the UK also throws open the question of what integration is actually meant to achieve and how to measure it. In our recent report, we found a huge range of different priorities and aspirations across 20 years of reforms, from boosting population health to saving NHS money. Progress was generally limited. Emergency admissions had not fallen, savings were not delivered, and surveys showed little sign that patients were having a better experience.
Does this mean integration doesn’t work? Or were we counting the wrong things – broad variables affected by many economic, social and health trends, often far removed from the immediate contact between different services? The complexity of integration makes it hard to define, measure and evaluate. Although it has been a policy aim across the UK for more than 20 years, we still have relatively little understanding of its impact. Much more therefore needs to be done to improve measures of integration, and set out clearly how it is supposed to contribute to wider outcomes.
In England's latest round of reforms, these questions have been put on the back burner. The integration white paper left central government to work out national priorities and how success will be measured, and local “places” to build these into “outcome frameworks”. The temptation to bolt on ever more national political priorities, and process measures with a long history in the NHS, will be strong. But there is a risk of very visible failure if ambitious, unachievable or irrelevant targets are piled onto a set of reforms which may not reach deep enough to drive significant change.