Chris Ham and Anna Charles outline the findings and recommendations of the health and social care committee’s review of integrated care development in the NHS
In a comprehensive review of integrated care developments in the English NHS, the health and social care committee of the House of Commons has rejected claims that these developments will lead to further privatisation of care.
Members of the committee were much more convinced by the evidence of NHS witnesses who are leading work on integrated care than arguments advanced by critics of the proposed accountable care organisation contract. Their convictions were strengthened by seeing at first hand examples of how integrated care is developing on a visit to South Yorkshire and Bassetlaw.
Evidence gathered during the committee’s inquiry, on which we served as advisers, convinced MPs from across the political spectrum that the direction set by sustainability and transformation partnerships and integrated care systems is the right one, even though some had doubts at the outset.
While supporting work across the NHS to develop integrated care, the committee calls on NHS England and national bodies to develop a much clearer narrative explaining what integrated care is and why it matters to patients and service users.
The absence of such a narrative has contributed to widespread misunderstanding in many quarters, reinforced by the use of language drawn from the United States.
The absence of a clear narrative has contributed to widespread misunderstanding in many quarters, reinforced by the use of language drawn from the US
The recent shift of terminology from accountable care to integrated care shows that this message has been heard and the priority now should be to communicate in plain English why this policy is being pursued.
Following a difficult birth, not helped by the lack of transparency associated with their development, the challenge faced by STPs and the ICSs is to build more effective partnerships both within the NHS and between the NHS, local government and the third sector, and to demonstrate that their aim is to improve health and care.
Changes in the law needed
A major tension here is how to strengthen partnership working in the context of the Health and Social Care Act 2012, which was designed to promote competition rather than collaboration.
The committee argues that NHS England and national bodies should work with the leaders in the health and social care community to identify changes in the law that are needed to remove obstacles to progress. These obstacles include requirements on commissioners to use competitive procurements when placing contracts and barriers to the merger of NHS England and NHS Improvement.
By drawing on the experience of leaders within the NHS, the aim would be to avoid another damaging top down reorganisation and align the law with the growing emphasis on collaboration.
Not surprisingly, the proposed accountable care organisation contract featured prominently in the committee’s hearings. Claimants who have brought one of the judicial reviews against NHS England relating to the contract argued passionately that it would lead to NHS care being contracted out to the private sector and should not be permitted to go ahead without a full debate and a change in the law.
NHS witnesses from Dudley and Manchester explained why they wanted to use the contract, in both cases arguing that it would be awarded to NHS bodies and that privatisation was not part of their thinking.
A major tension is how to strengthen partnership working in the context of the Health and Social Care Act 2012, which was designed to promote competition rather than collaboration
In view of the strength of feelings around this issue, the committee’s report recommends that the contract should be piloted and evaluated before being made available for use more widely.
Depending on the outcome, accountable care organisations, or integrated service providers as they are now called, would be established in law as NHS bodies to provide clarity on their role and accountability.
In the meantime, other areas of the country are making use of existing legislative flexibilities to integrate care, underlining that the new contract is only one way of making further progress.
A clear message from the committee is that on their own, STPs and ICSs will not provide a solution to the growing financial and operational pressures facing the NHS and social care. Tackling these pressures depends first and foremost on the government’s ability to deliver substantial additional public funding for both services and to recruit and retain the workforce needed now and in the future.
Integrated care has the potential to improve health outcomes, deliver a much better experience for patients and service users and ensure that resources are used more effectively but it would be unrealistic to expect more.
Greater Manchester illustrates the scale of the funding likely to be required. As part of its devolution deal with the government, the conurbation received £450m over five years from the national sustainability and transformation fund.
Tackling these pressures depends on the government’s ability to deliver substantial additional public funding for both services and to recruit the workforce needed
These additional resources have been used to pump prime the development of local care organisations in the 10 places that make up the integrated care system covering a population of just under 3 million. On this basis, the NHS in England would require around £9bn over five years to underpin its work to transform health and care.
Some of the additional resources the prime minister has promised for the NHS should be earmarked for this purpose rather than being used to reduce provider deficits as happened to the STF created in 2015.
Transformation is needed to ensure sustainability and it will not happen unless adequately resourced. Integrated care lies at the heart of transformation and the cross-party commitment in the committee’s report provides welcome endorsement of what is now happening in many areas.
Chris Ham and Anna Charles work at The King’s Fund and acted as advisers to the committee’s inquiry.