If only we could focus on the end rather than the means

My heart sank when we got a glimpse of Labour’s thinking about post-election health policy, with hints that hospitals would be expected to evolve into integrated care organisations providing all health and social care in an area.  

Don’t get me wrong, I believe passionately that we need much better coordination of care for individuals and their families, as like so many other people, I find myself struggling to organise properly integrated health and social care for frail older relatives. What bothered me about the suggestion of hospitals moving to become integrated care organisations was the implicit assumption that a single structural solution might be needed for what we know to be very difficult problems in the organisation of health and social care.  

One size doesn’t fit all

International health policy experts, including the likes of The World Health Organisation, Commonwealth Fund, European Commission, the International Foundation for Integrated Care and the OECD have been grappling for more than a decade with how best to care effectively for the expanding population of people living with multiple long-term conditions. And critically, the common truth emerging is that there is no one-size fits all solution.

Instead, the analysts and researchers are all clear that we need better ways of assessing what people want in terms of care and support, and then putting in place services that try to achieve these outcomes. In other words, we should focus on the ends, not the means.

Lessons from abroad

Governments presiding over universally funded health systems have a tendency to see something they think is good, and then mandate it for all, on the basis that national and consistent organisational arrangements are automatically the answer. There are lessons to be learned from doing things differently. In New Zealand, the independent practitioner associations (GP-developed and owned organisations set up to enable general practice to take on government contracts to deliver a wider range of community health services) resisted government attempts to abolish them in the early 2000s. Instead, the IPAs shifted their focus and worked with the grain of Labour health policy to concentrate on managing the health of local populations, whilst retaining their strong roots in general practice. The result is that New Zealand now has strong and effective primary health networks that are increasingly taking on the role of what we often call an ‘integrated care organisation’, and working in closer partnership with hospitals to better meet the needs of people with long-term health conditions. 

This takes me back to my concern about the apparent move to mandate a single model of integrated care organisation. It is clear from the rich variety of schemes emerging in response to the Government’s Integrated Care Pioneer programme that there are many ways in which health and social care can be tailored to local needs. Some of the pioneer projects are rooted in general practice organisation and initiative, others in strong partnership between the voluntary sector, the NHS and local government and yet others have been inspired by a local acute hospital working closely with community, primary and social care services. We need these kinds of experiments, and there is no doubt that acute hospitals should take a role in developing new forms of integrated care. Indeed, there are many examples of integrated care networks from other countries that demonstrate the value of including hospitals and specialists in their networks. 

The risks of large-scale restructuring

But the blanket approach of favouring hospital-led ICOs apparently suggested by Labour would carry some very real risks. Despite reassurances from Andy Burnham that the last thing he wants for the NHS is another top-down reorganisation, this policy preference could likely spark a large-scale restructuring, with community trusts perceiving their days to be numbered, hospitals moving to take over general practice, and NHS managers doing what they know best – implementing structural change. And this would undermine the sterling work already being done by the integrated care pioneers and many other primary and integrated care networks, GP federations and super-partnerships, keen to develop community-based alternatives to hospital care.

Structural change is the last thing the NHS needs right now. It needs investment and support to do that most difficult of tasks – carefully redesigning care and supporting professionals to make this happen. In some cases this will indeed entail a local hospital forming an ‘integrated care organisation’ with GPs and social care, but in many others the solution will take a different form. 

Politicians would do much better to mandate the desired outcomes for patients and their families, describing the basic standards of health and social care we can all expect to receive, and setting out in detail how this will be funded. But they will make a critical error of judgement if they appear to offer a single organisational solution to the NHS.