Integration is the health secretary’s “holy grail” and a central part of the NHS mandate, but big changes are necessary to make it work. Peter Brambleby explains what he believes needs to be done

Jigsaw puzzle


Integration has long been considered paramount to the delivery of seamless, cost-efficient health and social care services. However, recognition of the issue has led to little improvement and fragmented care remains a persistent problem at the interface between different services within the NHS and between health and social care. 

‘Have the NHS’ people become too institutionalised to turn these lofty ideals into reality?’

For too long, the debate has struggled to get beyond the theoretical. Policymakers and pundits alike have wrestled with the idea of what integration means in real terms.

“Anti-integration” or even “dis-integration” policy moves, such as the tariff-based system of episodic acute care, have been implemented without matching incentives around preventive work, community care or mental health, while the separation of social care has put up further barriers to change.

A top priority

As the NHS faces up to a huge financial challenge and a rapidly changing policy environment, the old inefficiencies have to go. Big changes need to be made and integration has moved up the list of priorities: the health secretary and his ministerial team have rightly recognised it as being the “holy grail” though their intentions will require significant support from other parties.

The recently published mandate from the government to the NHS Commissioning Board helps to provide clarity on what integrated care should look like.

The paper sets down markers for care improvement, taking into account patient-centred care, smooth transitions between care settings and organisations, and service user empowerment. Creative thinking to entrenched problems are required. The NHS is a wonderful institution but have its people become too institutionalised to turn these lofty ideals into reality? 

Local challenges

Integration needs an integrator. In its mandate, the government appears to have endowed the NHS Commissioning Board with this responsibility, envisaging that the board will drive and coordinate engagement with the multitude of local and national stakeholders. 

However, the duty of the board to respect local autonomy means there will not be a “one size fits all” approach to tackling integration. With a reform package that embraces further localisation, it is likely that the differences between areas will become even more pronounced. Local challenges will require local solutions, funded from local budgets.

So, with the NHS Commissioning Board setting the tone at a national level, health and wellbeing boards are steadily emerging as the best grassroots force for integration. In fact, integration lies at the heart of the health and wellbeing boards.

‘The jury is still out on whether collaboration and competition can exist side by side’

Membership will be broad, bringing together representatives from a wide range of organisations with responsibility for the commissioning and delivery of care.

These forums should generate joint strategic needs assessments and strategies that ignore the traditional boundaries between services and organisations concentrating on populations and setting the framework for integrated commissioning.

Decisive action

Health and wellbeing boards have the opportunity to bring the disparate parties involved in commissioning together around the same table and establish integration as the pivot around which the shared mission to bring health and wellbeing to local populations is centred. It is this type of collaboration that will drive change with impact.

Despite the government’s insistence that there is no conflict, the jury is still out on whether collaboration and competition can exist side by side in the NHS without having a detrimental impact on integration.

In fact, an HSJ survey of clinical commissioning group leaders found 73 per cent of respondents considered “requirements to introduce more competition and competitive procurement” were a barrier to integration.

Health and wellbeing boards will have an important role to play in this respect, providing a collaborative forum where competition elements can be tempered while collaboration is promoted and enhanced.

Encouragingly, the same CCG leaders expressed enthusiasm for integrating services and budgets. If the pending Care and Support bill stipulates that CCGs will pool part of their budgets with local authorities for people with long-term conditions, as has been suggested, government will be doing something more tangible to support the holy grail of integration that it espouses.

Decisive action followed by performance monitoring and recalibration is what is required to get the integration train rolling and keep it on track.

Peter Brambleby is the former director of public health at Croydon PCT and a member of The 2048 Group