The buzzword in the NHS is collaboration, but with the Health Bill steeped in competition, despite significant amendments, realising integrated care still seems a long way away. It’s time to focus, says Professor Bob Hudson.
Who would have thought it? The biggest C word driving the health reforms is no longer competition but collaboration – or integration, as seems to be the preferred term.
The government has leapt onto the assertion by the Future Forum that the debate has become “unhelpfully polarised”, with competition wrongly being interpreted as the opposite of integration, so now it is full steam ahead on both counts. New duties to promote integration have been belatedly bestowed upon the NHS Commissioning Board, Monitor and clinical commissioning groups, and the Future Forum, along with the King’s Fund and Nuffield Trust, has begun to meet to develop an integration strategy.
Can the NHS now rest easy in the belief that local strategies for integrated care will receive official endorsement? Not really. Integration is still very much the junior partner to competition in the NHS bill, notwithstanding the many recent amendments. In particular there have been no changes to the clauses that bestow unprecedented powers on Monitor to require national and local commissioners to put services out to tender, and to ensure competition is the main driver of NHS activity.
Indeed the challenges to integrated models from the Any Qualified Provider requirements are already coming in from the private sector – for example, in taking a case to the Cooperation and Competition Panel, Assura Medical in the East Riding is taking the remarkable view that the vertical integration of acute and community services in the area is ‘against the interests of the taxpayers’. Expect many more like this as private providers go for loss leaders.
In the meantime, established joint arrangements between the NHS and social care are collapsing. The implosion of PCTs has destroyed the high trust networks that have been developed with some far-sighted councils; some CCGs are already demanding to have ‘their’ community nurses returned from integrated teams; councils are withdrawing social workers from integrated mental health teams; and disputes about responsibility for funding continuing health care are escalating. Far from moving forwards, the collaboration clock is actually being turned backwards.
Despite the size of the bill, there is little clarity about likely trade-offs between competition and integration. Much will depend upon judgements from the NHSCB, and upon the relationship between the NHSCB and Monitor – currently complete policy unknowns. The role of Monitor, in particular, will be critical, but it is bound to see competition as its priority, and has no evident experience or understanding of collaborative working. It is easy to see integration meeting Sir Roy Griffiths’ classic description of community care in the 1980s – “everyone’s distant relative and nobody’s baby”.
This leaves local partners with an interest in developing collaborative solutions inhabiting a bizarre policy dysphoria. Ministers and officials frequently proclaim that integration is acceptable as long as it is not anti-competitive, but there is no clarity or certainty about what this might mean in practice. CCGs could easily find themselves being simultaneously admonished by the NHSCB for not promoting integration enough, criticised by Monitor for promoting it too much, and being hauled in front of the competition authorities by disgruntled private providers. And there will be ever fewer managers to cope with this fallout.
Surely the reality is that unless and until integration becomes the prime imperative in health policy, with competition being used only sparingly and appropriately, it will never flourish. The fragmentation within the NHS and the division between the NHS and local government persists precisely because these arrangements were hardwired into the basic organisational design in the 1940s. These structures are no longer fit for purpose. It is instructive to recall that the two white papers of 1989 – Working for Patients and Caring for People failed to even cross-reference each other! We are now much better at using the rhetoric of integration, but has our practice really improved all that much?
The truth is that competition and collaboration do not sit comfortably together – the issue is the extent to which one is traded-off for another. It is not unreasonable to assume that very little competition will be traded off in order to promote integration. Commissioners will be left spending unproductive time trying to find alternative providers able and willing to offer entire integrated pathways of care, or alternatively requiring all parts of each pathway to be open to AQP.
There is an alternative. The Welsh Assembly has brought together all of the NHS in streamlined health boards working with local authorities and supported by Public Health Wales. In Scotland the recent Christie Commission on the Future Delivery of Public Services is calling for ‘a radical, new collaborative culture throughout our public services’.
But in England we belatedly tack integration onto the agenda of the Future Forum, and insert a few weak clauses about ‘promoting integration’ into the amended Health Bill in order to keep the Coalition afloat. Patients deserve better!