Michael Macdonnell sets out the task ahead for sustainability and transformation partnerships
Making “the biggest national move to integrated care of any major western country”. That is the NHS’s ambition, set in the Next Steps on the Five Year Forward View published earlier at the end of March.
To make this ambition reality, the NHS needs increasingly to manage systems or networks of care, not just organisations. The traditional divide between primary care, community services and hospitals – which has prevailed since the birth of the NHS – is now all too often a barrier to the services people need.
Patients rightfully demand better integrated services. About 15 million people in England – more than one in four – have at least one long-term condition, and about 45 per cent of these live with more than one. Helping people to manage these conditions is now the NHS’s core business.
Harder to achieve
Doing so well requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. It means organisations must work together, integrating services around patients.
Integrating health and care systems is also a big part of the answer to the financial pressures facing the NHS. Providers have achieved impressive efficiencies – 3.7 per cent in the last financial year – and they will need to continue to do so. But these are getting harder to achieve.
We need to focus on system-wide opportunities, including reducing avoidable demand and sharing assets and services. Some providers may not be viable over the longer term unless they are networked with others. Addressing workforce pressures – in some specialties and parts of the country – will also require stronger and more organised clinical networks across organisations.
In integrated systems, providers and commissioners are prompted to ask searching questions about the return on each pound of public spending, helping to make better decisions about how to allocate constrained resources. We can no longer afford wasteful contracting rounds where providers and commissioners compete to gain the upper hand. Acting as a system, the NHS can be more than the sum of its parts.
STPs are not about cutting services. They are about making the most of each pound of public money
This is what sustainability and transformation partnerships are for: they are vehicles for integrating systems and funding. At their best, they bring GPs, hospitals, mental health services and local government together to plan safer networks of care and to integrate services around patients, particularly those whose needs don’t neatly fit into the system’s traditional institutional silos.
STPs are not about cutting services. They are about making the most of each pound of public money and implementing improvements beyond the purview of any single organisation.
Some parts of the country are ready to go further: to take collective responsibility for improving the health of their population within a defined share of the NHS budget. The ‘accountable care systems’ we announced last month will, like other areas, be taking steps to take the strain off A&E, make sure people can get a GP appointment quickly and to improve mental health and cancer services.
But they will also be implementing new models of care that prevent or proactively manage illness before a stay in hospital is the inevitable result. This will be particularly important for older people who can often face a revolving door of emergency admission, delayed discharge and then hospital readmission.
In implementing these new care models, accountable care systems will draw on the best of the vanguards. The PACS and MCP vanguards (two forms of accountable care) have seen lower growth in hospital and emergency inpatient bed days than the rest of England.
In the latest available data, per capita emergency admissions growth rates were 2.7 and 0.7 percentage points lower respectively than the rest of England when compared to the 2014/15 baseline. Per capita emergency bed days growth rates were 1.7 and 0.7 percentage points lower.
And patients are benefiting from more joined/up care which is focused on keeping them well. These benefits have been achieved through population health approaches that target multidisciplinary teams at people at risk of becoming acutely ill and intervene before they deteriorate. These redesigned care models are the indispensable foundations of integrated care.
So the challenge ahead is to develop effective health systems that can improve and integrate services while managing within their share of NHS resources. To help this happen, national bodies also need to behave differently – less as regulator and more as support agency.
That’s why we’ve brought together a new team that combines the new care models programme with support for STPs and accountable care systems. Its job will be to get alongside system leaders to improve services and do so in a way that others can plagiarise with pride.
Far from a distraction from the day job, building health systems is central to fixing the fragmentation of urgent and emergency services, to providing more joined-up care, preventing unnecessary hospitalisations, and to maintaining the NHS’s financial sustainability.
As the proverb goes, to will the ends is to will the means, so we invite every STP to get on with the job of building a meaningful and effective partnership, capable of charting its own future.
Michael Macdonnell is director of transforming health systems, NHS England.