Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by deputy editor Dave West.
The NHS long-term plan has landed. I’ve picked seven things about integration in there which might have passed you by:
…it’s still there: OK you probably spotted this one, but it’s worth reflecting that integration is still prominent despite all the challenges and sceptics. The approach is largely consistent with the past couple of years too – spreading integrated care systems and primary care networks.
…the missing baseline: The smoke and mirrors of any good NHS strategy mean all the big players can be told they’ve got a healthy share of the spoils – acute trusts are certainly being told they will fare much better.
Primary medical services and community health are promised “at least £4.5bn” real terms growth over five years – up £1bn from a promise included in a hastily compiled press release in November, a change due mainly to a shift in the budgets covered.
The trouble is, neither government nor NHS England will say what this baseline is, nor how much in percentage terms these budgets will grow. It means growth for out of hospital services could be anything from just a slither above the NHS overall – not enough for a major shift.
It could also be delayed away to the second half of the five years. A new GMS and “network contract” deal, promised in the near future, should tell us a bit more.
…primary care networks as providers, employers, trainers, IT buyers, and budget holders: One of the big reform hopes in the plan is primary care networks, with a lead role in “creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care”.
They are cast as trainer and employer of expanding non-GP primary care teams, providers of multidisciplinary teams, buyers of IT, and recipients of fairly substantial funding, and will need to select an “accountable clinical director”.
It’s more evolutionary than trying to create accountable care organisations (per 2014-15), but in plenty of places PCNs are virtually non-existent, there is widespread misunderstanding of what they are meant to be, and lots of culture clash among GPs, GP federations, community health staff, commissioners, and others who have a stake. It’s not clear where this will lead.
…integration targets on the way: With the core hospital targets in limbo, there’s a clear suggestion of waiting time standards for community crisis response (two hours) and reablement (two days), as well as mental health crisis care.
There’s a fresh proposal too to create a measure of integration – an “integration index”, an idea that’s occupied wonks in the past but remained elusive in practical terms.
…typical: England will be covered by ICS by April 2021, and “typically” each will have only one clinical commissioning group. Do get in touch if you think your area is typical – I won’t hold my breath.
It’s also not taken as given – Simon Stevens told MPs yesterday – that 42 STPs will translate to 42 ICS. Many will want to split their STP. Nothing in the long-term plan speaks of a move to straightforward or uniform organisational arrangements soon.
…local government and social care tensions: The plan suggests the NHS could take back control of some big public health services which have been cut more steeply in recent years since they passed to council control (mainly owing to big grant cuts from Whitehall).
There is cold water for the better care fund, saying it is “in need of review” and has “sometimes been used to replace core council funding rather than add to investment at the interface between health and care services”.
It highlights the enormous unresolved problems – widely highlighted – from governments’ failure to grasp social care underfunding, and those services’ relationship with the NHS.
…the market is not quite dead yet: The thrust of the plan is forget competition, get collaborating. But, although the purchaser-provider split is very blurry, its death has been exaggerated.
Procurement decisions will be reserved for (enlarged) CCGs. Trusts will not be entrusted en masse with block budgets.
There’s even a 2002 throwback policy, with patients who reach six months on a waiting list offered “faster treatment at an alternative provider, with money following the patient”.
Meanwhile, NHS chief execs attending briefings with NHS England and Improvement bosses before Christmas heard multiple updates and expectations focused on individual organisations, not systems, in particular from NHSI.