Everyone, from government to health charities to individual patients, agrees that integration is a key component of successfully improving the care of patients. But the worry is that the focus on competition will push integration off the agenda. National Voices director of policy Don Redding speaks up.
“Integration, integration, integration” was the cry arising as final submissions went into the NHS Future Forum.
Research suggests it: the King’s Fund extolled the benefits of integrated services and proposed a closely argued model.
Management wants it: the NHS, via the Confederation, called for mechanisms and incentives to help the whole system “pull together”.
Social care desires it: the Association of Directors of Adult Social Services asked for a reformed care model, with all relevant services “integrated around the individual”.
And patients demand it. Integrating services around patient needs, so that care is seamless and information follows the patient, is seen as the essential foundation for the other building blocks of person-centred care.
It is hard, in a fragmented system that waits passively for people to present with illness, to work proactively with patients, service users and their carers to build health literacy, support for self-management, and participatory care planning.
For its submission to the Future Forum, National Voices reviewed all the positions it had taken since the white paper, and went through two further rounds of consultation with its more than 100 member charities, to produce “9 big shouts” for changes to the government’s reform emphasis.
Integration was at the top. As patients we are sick of falling through gaps, hitting organisational barriers that prevent our access to support, and assuming chasing after information about what we need and where to find it. We want services to be seamless and care to be continuous.
When we talk about integration, we don’t mean dominant hospitals swallowing up other providers. We mean that primary and community health services, social care, and voluntary sector support should mesh together to create a support package of services meeting our clinical, caring and educational needs.
That requires reorganisation. National Voices’ members have said since before the general election that patient, service user and carer organisations can support radical change, if it is done in partnership with us, and focuses on our second ‘big shout’ – the right care in the right place at the right time.
What has happened to the QIPP agenda here? National workstreams – on long term conditions and shared decisions, for example – continue to develop a progressive, patient-focused agenda. But they seem to have little connection to the NHS system.
Locally all we see are short term cuts by PCTs hardening their referrals and acute trusts bringing down bed occupancy. In the “big shouts” we call for up-front investment in new models of care and treatment.
It is clear the government has heard the calls for integration, so how could it respond?
We do not want token changes to the bill to make it more “acceptable”. Tweaking Monitor’s mission alone will not suffice.
To get this system to pull together means focusing on integrated services as the key to meeting the Nicholson challenge – and lining up all the reform ducks behind that goal.
Here are some suggestions made in National Voices’ “9 big shouts” document:
- Switch the reform emphasis from ‘competition’ to ‘integration’. Give all parts of the system, including Monitor and the commissioners, a duty to collaborate – not for its own sake, but ‘for the purpose of achieving integrated services’. Mount a rapid expert policy review to determine where competition can be used as a means to promote better integration.
- Give a political commitment now that in the first three annual mandates to the Commissioning Board, there will be a key focus on outcomes relating to service integration.
- Create commissioning signals and incentives to expand the care trusts programme, learning from pilots like Torbay that have modelled the combination of efficiency gains and better outcomes for patient health and experience that the Nicholson Challenge requires.
- Switch the emphasis of choice policy to supporting the choices patients say are most important – choices of treatment and of care package.
- Likewise move the priority for the information revolution away from producing reams of performance data. The three priorities here are, first, to get accurate information to be shared by clinicians and to travel with the patient through their contact with different professionals and services; second, to ensure that people get the information they need to organise their lives, manage their conditions and choose their care and treatment; and third, to accelerate patient access to records.
- The bill, and the new system it creates, must make it possible for patients, service users and carers, and their organisations, fully to enter the heart of the commissioning system, to guide the development of services towards maximising benefits and experiences.
There is massive untapped value in the form of patient expertise in providing consumer feedback, contributing to service design, providing tailored support services and patient-focused information, and challenging vested interests to re-engineer provision.
The outdated, token concept of ‘consultation’ must be replaced by co-design, co-commissioning and co-production of public value.
For patients and service users to have genuine influence, there must be significant lay representation on the governing bodies of the commissioning organisations.
Integration, then, is a demanding agenda. Deputy prime minister Nick Clegg recently asserted that, “We are striving to create services that are much better integrated”, not fragmented.
But the reforms and legislation seemed so emphatically bent towards localism, competition and ‘hands-off’ autonomy. Can they now be steered around to face the goal of achieving co-ordinated, collaborative services that patients experience as seamlessly supportive?