Supplement: Everybody’s talking about integration but can the NHS deliver?

When Jo Webster first read the NHS Five Year Forward View, there was a lot in it that she recognised. As chief officer of Wakefield Clinical Commissioning Group, she was already a strong advocate of the themes in Simon Stevens’ vision document, not least around integration.

“We’ve been working on breaking down traditional barriers for some time,” she explains. “We recognised at a strategic level that we needed to do something dramatically different, something that had strong public engagement, and involved partnerships with teeth.

‘There are areas in the UK such as Torbay and Wigan where integration is working well’

“We decided that the best way forward was to take a collaborative approach to allow providers to work with us and with each other.”

Last month it was revealed that Wakefield CCG was one of 29 organisations that successfully bid to become a vanguard site for the New Models of Care Programme.

Making the announcement, NHS England said it was one of the first steps towards delivering the forward view and supporting improvement and integration of services.

It is clear that there is high level political support for integration. Not only is it a focus of the forward view but it is also backed by serious resources: almost two years ago, the government announced establishment of the better care fund, a £5.3bn investment intended to incentivise the NHS and local government to work more closely together.

Although this fund has been accused of being too bureaucratic, even its critics recognise that it is well intentioned. But will it be enough?

Hugh Alderwick, programme manager for integrated care at the King’s Fund, says that, while there are reasons to be optimistic, action is needed.

‘We recognised at a strategic level that we needed to do something dramatically different’

He is joint author of a King’s Fund report, published in February, Population Health Systems: Going Beyond Integrated Care, which calls on policy makers and leaders to go beyond integrated care to improve population health.

“People have been talking about the need for integration almost since the health service was founded, and certainly since the 1960s,” he says.

“It’s something that we’ve been trying to do for a very long time, but people have found it very difficult.

“There’s a political will to make it happen and there’s general acceptance that it’s a good thing, but the policy barriers still exist.”

Barriers to integration

The barriers he lists are familiar, and include payment systems that disincentivise joint working andfragmented commissioning arrangements.

Nevertheless, Mr Alderwick points out that there are areas in the UK, such as Torbay and Wigan, where integration is working well.

“But that doesn’t mean it’s the norm,” he says.

So what are commissioners and providers doing to make integration a reality?

Wakefield CCG is a vanguard site in the category of enhanced health in care homes – offering older people better, joined up health, care and rehabilitation services.

‘We’re looking to a systems shift from delivering care to prevention’

But the local health economy’s approach to integration does not stop at the care home door. Rather, health services, social services and others are working together to provide better joint services across the board.

The new processes are being led by an integration executive group, headed by Ms Webster and Andrew Balchin, the Wakefield Council corporate director for adults, health and communities.

Commissioners and providers – including social enterprise, community and third sector representatives – are equal partners in the group, which is also responsible for the area’s £42m pooled budget from the better care fund.

Early work as part of a joint health and social care “Connecting Care” programme has united specialist community nurses, social workers, therapists and workers from voluntary organisations, such as Age UK, in single teams. The teams are in hubs tied to networks of GP practices.

Shift to prevention

Mr Balchin would like to see this go further. “We’re looking to a systems shift from delivering care to prevention,” he says. “We talk about things like ‘better care’ and the Care Act, but I think that’s only half the picture – we want to stop people needing care in the first place.”

‘Integration isn’t an end point in itself: it’s part of the journey’

There is no silver bullet to make integration work, says Ms Webster, but a key element is ensuring commitment to collaboration at every level, from leaders to frontline staff; investing in strong strategic leadership was key.

“There’s lots more to do but we are delivering,” she says.

It is not only the vanguard sites that are taking a lead on integration. City and Hackney CCG, for example, is taking an innovative approach to integration and collaboration for frail older people and those at the end of life.

The One Hackney Alliance is made up of a group of local providers including acute, community and mental health trusts, the local authority, voluntary sector, GP confederation, and out of hours provider.

Last year the CCG charged this alliance with designing joined up services for the local population. Payment is contingent on outcomes suggested and agreed by the alliance itself.

‘Dedicated project resources are crucial to making things happen’

“The health and social care economy was already performing quite well but we wanted to better support collective leadership and shared decision making across the local provider community,” says Mark Scott, programme director for integrated care and urgent care at the CCG.

“Essentially, we set out the commissioning challenges and then put the responsibility on the providers to work together to find solutions. It’s a recognition that no single part of the system is solely responsible for reducing hospital admissions, or getting people out of hospital everyone has their part to play.”

There are good relationships with the local authority, which has been supported by the preparation for the better care fund, he adds.

“I think the benefit of this approach is that it encourages local provider ownership of both the problems and of the solutions.”

‘The benefit of this approach is that it encourages local provider ownership of both the problems and of the solutions’

aul Jenkins is chief executive of Tavistock and Portman Foundation Trust, one of the providers in the alliance. He also chairs the One Hackney programme board. He believes that taking time to build trust and relationships has been vital.

“Don’t underestimate the time it takes,” he says. “It’s also been important to have dedicated project resources. Too often these initiatives are done by busy people in their spare time, but dedicated project resources are crucial to making things happen.”

Information challenge

Sharing information remains a challenge, Mr Jenkins says, pointing out that if the systems allowed better sharing of care plans, for example, it could prevent hospital admissions at end of life.

The trust came into the alliance as a specialist provider of psychotherapy in primary care, but he believes that its wider involvement has helped to ensure a strong focus on mental health and has helped foster an ethos of reflection.

‘The language battle has been won – everybody is talking about integration’

From a provider perspective, he says he is a fan of the alliance system. “It’s an attractive model to get providers to work together,” he says. “It’s in everyone’s interests to make it work.”

Mr Alderwick hopes national and local leaders will seize opportunities to build on integration to improve population health.

“The language battle has been won – everybody is talking about integration,” he says.

“It’s great that it’s becoming an established thing. But we need to be clear about what we actually need.

“Integration isn’t an end point in itself: it’s part of the journey, and should be part of a broader shift to improving population health and wellbeing.”