Four years ago, the Five Year Forward View set out a bold new vision for the NHS and for care services in England, signalling a significant shift in how the health service was to be organised. The vision, which has been reinforced and extended with subsequent announcements and initiatives, including the creation of sustainability and transformation partnerships, aims for integrated systems delivering seamless care across different organisational boundaries to local populations. The term ‘place based’ was coined to convey the idea that interlocking services would be commissioned and delivered by a coalition of health and social care providers to people in a defined geographical area.
A flurry of activity and debate followed, and much has been written about these new systems, their complexities and their potential. Much less attention has been given to who the players within the coalition might be. It is striking that the debate has almost exclusively focused on the NHS, and any mention of non-NHS organisations (other than local authorities) has been largely absent.
We held a roundtable with a range of different providers, with representatives from the NHS and non-statutory providers (voluntary, private and social enterprise), as well as NHS and local authority commissioners, to explore how the latest reforms have progressed in reality. Although the conversation revealed a mixed picture, one participant from a non-NHS organisation commented: “from the outside it looks like integration of the NHS within the NHS”.
In the scramble to create STPs – first the plans then the partnerships – there appears to have been little consideration of the fact that ‘health economies’ are complex ecosystems involving a multitude of different types of provider. In fact, around 11% (that’s £13.1 billion) of the total health budget is spent on non-NHS providers, including local authorities, independent providers, the voluntary sector and social enterprises. £8.8 billion (67% of the non-NHS spend) is spent on independent sector providers, and a further £1.6 billion on voluntary and community sector (VCS) and other non-profit providers. In response to government policy designed to drive plurality of provision, the proportion of health spend outside the NHS has been rising, and that rise has been proportionately greater in the VCS than in the independent sector.
What this means is that, in any local health system in England, you are likely to find not only multiple NHS organisations, but also a diverse range of private and voluntary organisations and social enterprises providing services alongside them. Contracts with non-statutory organisations range from large-scale community service provision through to tiny bespoke services targeting a particularly population group. With the recent boost to social prescribing of £4.5 million being invested in voluntary and community sector schemes, it is likely this sector will expand further.
What is standing in the way of an integrated future?
Given this reality, why has a more comprehensive version of the integrated care vision been largely absent from mainstream debates? The ongoing and divisive debate about privatisation, which has been thrown into the public spotlight yet again, has probably acted as a distraction from a debate about the real value of the non-statutory sector in delivering integrated care, and clouded the original, inclusive vision.
Our roundtable identified a shared set of both new and well-established challenges that are posing barriers to progress towards that vision, which we identify here.
1. A lack of clarity about governance and accountability
Perhaps the most significant challenge to progress identified at the roundtable was a lack of clarity around leadership and governance for those ‘outside the tent’.
Participants across all types of non-statutory organisation reported difficulty in identifying how decisions are made within STPs, and who the key decision-makers are. There was a sense that many STPs are opaque organisations that have so far demonstrated little transparency in how they operate. The challenge for those outside the NHS is in knowing how to engage and who to engage with.
2. A lack of shared vision
While the official purpose of creating integrated care systems is to improve health and to deliver more joined-up care to their populations, the financial realities mean there is also an imperative to increase productivity and efficiency. Although those two objectives are not necessarily at odds (and indeed a lot of the integrated care literature demonstrates the two can be aligned), there was a feeling among participants that STP leaders had not consistently created a shared vision setting out a direction of travel that everyone in the ‘footprint’ can believe in.
The conversation revealed a suspicion among those outside the NHS that this agenda is less about integration and more about solving the NHS’s financial woes. Such suspicion was eroding trust in some areas, and not facilitating the creation of new cross-sectoral relationships. Learning from the body of evidence around what helps and hinders integrated care tells us that trusting relationships are at the heart of any successful integrated care initiative.
3. Timescales for engagement
Building those crucial cross-sectoral and inter-organisational relationships, underpinned by a sense of trust, takes time and energy. This has been demonstrated time and time again in various integrated care initiatives. STP leaders at the roundtable referred to the lack of time available to them to do as much engagement as they would like.
Although some localities already had well-established relationships across different sectors, some participants talked about those having been disrupted as the rules of engagement shifted and uncertainty about the ‘rules of the game’ crept in.
4. Existing dynamics
The above three points have arisen as a direct result of the shift in policy. However, there existed a range of issues that pre-date these recent changes that, in some cases, have exacerbated new challenges. The fragmentation of the VCS, for instance, is one such issue – well documented elsewhere and reiterated at our roundtable – and it continues to pose challenges for commissioners who lack the resources to interact with multiple small providers.
The recent period of uncertainty has also been a particular challenge for smaller VCS organisations, who are already highly sensitive to the annual or sporadic cycle of contracting, as they generally lack reserves to fall back on during uncertain times.
Existing challenges are not confined to the VCS, of course. For example, private sector organisations also voiced concerns about how they are often treated with suspicion by NHS commissioners and other providers, which makes it difficult for them to engage in a local health economy.
5. NHS awareness of non-NHS capacity and capability
Although many of the issues under discussion focused on the challenges within the non-statutory sector, the conversation also highlighted that many commissioners remain unaware of the full capacity and capability available outside the NHS, and that there is untapped potential that could be better exploited if the barriers to engagement were overcome. Commissioners at the roundtable acknowledged they often struggle to keep abreast of the offer from non-NHS providers.
So what can be done?
The development of integrated care requires some different ways of working for providers from all sectors and for commissioners. In his recent article on the implications of integrated care on commissioning, Nigel Edwards noted that “by creating a system where the detailed transactional activities are shifted towards provider entities, there is an opportunity for commissioners to put greater focus on setting a vision for population health”. By extension, that also means there are opportunities to engage with providers in setting that vision, and for providers to interact in new and different ways.
But, as our discussion illuminated, there are barriers to making that a reality. So what needs to be done to overcome them?
Having a truly shared vision helps to develop trust and relationships across different sectors that will be so crucial to advancing this agenda. However, as is apparent from our discussions with leaders within and outside the NHS, there is work to be done to bridge the cultural divide that exists between sectors.
For that to happen there needs to be clarity about governance and accountability. Commissioners across health and social care, and indeed the wider public sector, need to be transparent in their approach to engaging with providers – and others such as patient groups – in developing their vision and in setting the ‘market rules’ that will govern the way in which they expect providers to behave. Clarity over the issues they are seeking to address, and over what success would look like, would help to keep the journey towards an integrated system focused.
Providers – including NHS providers – in turn need to consider how they form partnerships both within and across sectors that will enable them to play a full role in the delivery of that vision. The VCS has recognised that it needs to take a more strategic approach to how it engages in this agenda. Private sector participants acknowledged that the sector itself could do more to combat suspicion by being more transparent in its objectives, and offering greater clarity about the role it would like to play in health. A distinction was drawn between organisations that want to provide a specific product or service in isolation, and those that would like to operate more as a partner along a pathway of care.
Providers across the spectrum need to offer greater clarity about what they bring to the table, and be able to make a strong business case (aligned to local priorities) for their contribution. Providers and commissioners alike need to work together to undertake an honest assessment of the capability and capacity of the local non-statutory sector, in order to identify untapped potential and service gaps.
Such an assessment would form strong foundations for commissioners to develop an appropriate approach to procurement, tailored to local circumstances. NHS commissioners could look to their local authority counterparts for learning around how best to use the Public Services (Social Value) Act 2012 within this process.
But perhaps the first vital step on this journey is in defining the ‘place’ and the measures of success that will be meaningful within that place. However, the complexity of defining ‘place’ that is meaningful to all should not be underestimated. And each ‘place’ may, in reality, be a series of different and overlapping footprints that serve different purposes at different scales.
For instance, a high-level vision may be created across a large footprint, but that might be complemented by a set of more local ‘places’ meaningful to a population where that vision is implemented, and within which smaller organisations can make a valuable contribution. The integrated care provider contract, which is currently the subject of consultation, could be one mechanism that helps to define ‘place’ at that more micro level.
Of course, a lot of what we have discussed here comes down to behaviour change, and experience tells us that is not something that happens overnight. A great deal of time and effort will need to be invested in getting this right, and a certain amount of flexibility at a local level will be required. However, there is reason to be optimistic. The emergence of devolution in recent years has demonstrated that progress can be made, and there are signs that some local system leaders are beginning to look beyond their own sectoral boundaries to take a more population-based view.
There is potential to make this vision a reality, but success depends on everyone across all sectors recognising that a sense of place must be grounded in a spirit of openness and inclusivity with give and take on all sides.
Buckingham H and Curry N (2018) "Working across boundaries: realising the vision of integrated care", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/working-across-boundaries-realising-the-vision-of-integrated-care