Care integration is the goose that must lay the golden egg

The NHS Five Year Forward View was jointly authored by six national bodies but is seen by many as Simon Steven’s personal road map for the NHS. It has received a warm response from those in the NHS, as well as the wider political class.

Many on the front line of the NHS will have breathed a sigh of relief that, while its broad direction is clear, the details of the journey are far less didactic than they might have been.

At the heart of the forward view are the so called “new models of care”. Some, such as the creation of urgent care networks or midwife led services, feel more akin to a confirmation of an established trend.

The two that are most intriguing and, arguably, that presage the most radical change relate to care integration - specifically, the proposals for multispecialty community providers and primary and acute services.

‘Both models are designed to achieve the same ends’

Both models are designed to achieve the same ends: greater integration between primary, community and specialist care through organisational alignment, reinforced by financial incentives.

What’s old is new again

Of course, seasoned NHS observers might well ask how “new” these models really are. For example, the idea of hospitals providing general practice services was raised as part of the Acheson report into London’s primary care in 1981.

Similarly, multispecialty community providers were very much in mind when the NHS (Primary Care) Act 1997 was introduced - “PMS Plus” (personal medical services) pilots were intended to (and in a disappointingly small number of cases did) allow primary care organisations to incorporate specialists into a multispecialty group formed on list based general practice.

‘Both models draw heavily on the experience of managed care organisations in the US and elsewhere’

This theme was echoed again in Lord Darzi’s NHS Next Stage Review, although most of the “integrated care pilots” that resulted lacked the scale anticipated this time around.

Both models, of course, also draw heavily on the experience of managed care organisations in the US and elsewhere.

So, if the NHS has been here before and failed to translate aspiration into delivery, why should we pin our hopes on these new models of care? There are a number of reasons to think that it might just be different this time around.

Why they work now

First, we see the rapid evolution - after many years of debate - of general practice federations providing a coherence and power to primary care.

For too long GPs have been either absent from the debate on broader service change, or simply without the scale and organisation to take on a significant or driving role. And without general practice at the table, any attempt to integrate care will be partial at best.  

Second, earlier attempts to create integrated organisations were in some cases treated with suspicion by the wider NHS system.

‘Earlier attempts to create integrated organisations were treated with suspicion by the wider NHS system’

Trailblazers seeking to shift care out of hospital and into primary care sometimes faced concerns about their motivations, or about the impact of their plans on wider health system stability; they had to make their plans work despite, not because of, the system. It feels significant that these models are now being championed from the very top.

The third reason for optimism is that the competition for resources between different parts of the health and care system has now become far more nuanced.

Previously the transfer of care and resources from hospital to primary and community care was seen to be a zero sum game, with hospitals digging in their heels to hang on to their revenue streams.

Now, there is a far greater commonality of objective.

Meeting the rising demand for non-elective services generally results in a financial loss for hospitals (although the latest tariff changes will attenuate this somewhat), but also operational disruption and missed targets.

Primary benefits for all

Many hospitals are seeking to manage services within an environment of scarcity - limited estate, recruitment problems and not enough money - so a vibrant and growing primary and community care sector offers opportunities for all.

‘The days of relying on annual incremental cost improvement programmes are surely over’

The forward view is placing great weight on the efficacy of these new models of care. And if care integration cannot close the health, quality and financial gaps outlined in the report, then what can?

The days of relying on annual incremental cost improvement programmes are surely over. Providers and commissioners need a far more fundamental change in demand management and efficient supply if they are to remain sustainable.

In this context, integration is a goose that simply must lay a golden egg.

Richard Lewis is partner at EY and a health consulting leader