'Integrated care should be this decade's number one priority'

In its June 2011 summary report, the NHS Future Forum said: “We need to move beyond arguing for integration to making it happen.” The report called for the commissioning of integrated care for patients with long term conditions, complex needs and at the end of life, building on ideas the King’s Fund and Nuffield Trust had presented as part of the Health Bill listening exercise.

Our findings, published today, argue that developing integrated care must assume the same priority over the next decade as reducing waiting times was given during the last. Government policy should be founded on a clear, ambitious and measurable goal to improve the experience of patients and service users and to be delivered by a defined date.

This goal would serve a similar purpose to the aim of delivering a maximum waiting time of 18 weeks for patients receiving hospital care. Its purpose would be to set a specific objective around which the NHS and local government could coordinate their activities to improve outcomes for populations.

This goal should be reinforced by guarantees that patients with complex conditions will be entitled to an agreed care plan, a named case manager responsible for coordinating care, and access to a personal health budget where appropriate.

Many of these measures are already an established part of health and social care policy but they have not been implemented consistently across England. Making them happen is therefore less to do with extra spending and more related to variations in local policy and practice that need to be tackled as a matter of urgency.

Our emphasis on making a difference for patients echoes the argument of the charity coalition National Voices that achieving closer integration of care offers the greatest potential to improve quality and safety. Delivering services in a joined up way around the needs of patients with complex needs should be an imperative rather than an optional extra.

Compelling narrative

We also argue that the government should create an enabling framework designed to embed integrated care across the health and social care system over the next five to 10 years. The starting point for this is for the Department of Health to articulate a clear and compelling narrative that places integrated care at the forefront of the hearts and minds of everyone working in health and social care.

This framework should include a number of elements:

• The DH must create an environment in which integrated care can flourish by doing more to align governance and accountability frameworks.
• Commissioners should be encouraged to modify financial incentives, test capitated budgets and bundled payments, and design new contracts that incentivise the delivery of integrated care.
• Providers should be given freedom to develop new models of care, with general practices encouraged to federate and integrate with community health services and social care, to deliver services 24/7 in the community.
• The NHS Commissioning Board and Monitor should provide clear guidance on how competition rules should be applied, and a more nuanced interpretation of choice is needed to empower patients in making real choices about their care.
• Support should be given to independent and third sector providers to develop new models of care.
• The DH and the commissioning board should facilitate a programme of organisational development and support, and provide guidance on how progress should be evaluated locally, and monitored centrally.

In putting forward these arguments, we are clear that there is no one best way of commissioning and providing integrated care. The DH and commissioning board should therefore avoid taking a prescriptive approach and instead support different approaches based on “discovery and not design”. As this happens, the focus must be on clinical and service integration, rather than organisational integration, and it should be centred on patients as well as populations.

Integrated care can be delivered without further legislative change or structural upheaval and, importantly, would be embraced by the professions and NHS staff. This provides an opportunity for change to be locally led and supported by the centre, rather than imposed from the top down. If executed well, the approach we have set out not only offers the opportunity to significantly improve care for those people who need it most, but it will also help deliver the productivity improvements on which the future of the NHS depends.

The challenge now is to make integrated care a “must do” priority that becomes the main business for health and social care. Pioneers in areas like Torbay have shown the benefits of working in this way, and others must follow their lead.

• Now read: “Integrated care needs a goal”, says Chris Ham