Why the NHS’s 10 year plan must grasp the nettle of plural provision within integrated care systems

A diverse provider market in the NHS is a fact of life (67 per cent of out of hours services delivered by social enterprises; 40 per cent+ community services by non-statutory providers) and as the NHS looks to develop its 10 year plan, these providers will be vital in helping deliver on its aims.

However, these organisations (who provide high quality care and consistently receive Care Quality Commission ratings above the NHS average) sit at the margins of planning and operationalising integrated care systems and are rarely mentioned by policy makers (eg there was no mention of either independent sector organisations or social enterprises in the Five Year Forward View).

Plurality, a must priority

It seems to be a convenient fiction for government and policymakers at the moment that NHS services are only provided by NHS organisations. Plurality of provision in the NHS, therefore, sits at a crossroads and we believe setting out how plurality and integration can co-exist needs to be a priority for the 10 year plan.

The Health and Social Care Select Committee have helpfully made clear in their recent report that a diverse healthcare market made up on NHS and non-statutory providers is fully compatible with integration.

Indeed, it’s care, not organisations, that need to be integrated and the NHS must tackle the real barriers to integration

This is borne out through international experience where “accountable care” systems akin to those being created by the NHS foster and maintain complex supply chains involving a wide range of players. They are de facto not large scale monopoly providers that attempt to do everything themselves.

Indeed, it’s care, not organisations, that need to be integrated and the NHS must tackle the real barriers to integration – lack of information sharing, lack of commissioning expertise, digital technology, bureaucratic admin processes, and longstanding cultural divisions between services.

The challenge is to design the right way for partnerships to develop along the patient pathway, and not for NHS organisations to close ranks and “repatriate” services in the mistaken belief that integration will automatically follow.

So what does the 10 year plan need to include to preserve the benefits of a diverse range of providers? Four key points are:

• Making good on the recent CQC recommendation in their “Beyond Barriers” report which said that the non-statutory provider sector needed to be “equal players” in local system planning. Integration and coordination of care won’t work if only a sub-set of services are integrated. We need to create mechanisms for engaging with all operators in local systems and the patients they serve.
• Retaining clear oversight and an accountable commissioning capability to plan and secure care. In localities it needs to be clear which organisation is ultimately responsible for the quality of care delivered and they need to be held to account for transparently delivering that. This must retain the power to bring in new operators to a local system where there is clear and persistent service failure whilst simultaneously making cooperation and partnership the norm.
• Charting a course towards designing services around decisions taken by patients. Technology and consumer expectation are already driving real change and by 2028-29 the way that citizens access services and seek care will change beyond recognition. The 10 year plan must welcome that innovation into every part of the NHS and send a clear signal that the NHS is open to new ideas. At present the NHS does not adopt at scale and has a patchy record on innovation. Those organisations that sit outside of statutory control can be more agile and have the entrepreneurial mindsets to innovate.
• Celebrate organisations demonstrating excellent employee engagement and patient satisfaction. The “long term plan” will not even get off the blocks if we don’t focus on retaining and recruiting the essential workforce. Social enterprises have exemplary employee engagement compared to many of their NHS peers, and in a recent report the CQC praised independent providers for their high staff morale and engagement with patients. Let’s learn from this expertise.

The NHS is undoubtedly on a path towards integration but is at a crossroads when it comes to plurality of provision. If the NHS wants to get serious about tackling the real barriers to integration though, then we need to get the right systems in place to allow the non-statutory sector to play its role in achieving this. Otherwise we could end up with exactly what we don’t want – an unresponsive “like it or lump it” service for patients.