The settlement for the NHS must earmark funds for transforming services
4 min read
Integration may not save money and in the short-term it could cost more – but success must be judged by whether it delivers a better experience for patients and those looking after them, writes Sarah Wollaston
For patients, the best integration is unseen and simply enables them to have a frictionless experience moving between services in the health and care system.
Since the Health and Social Care Act 2012, organisations trying to work more closely together have been held back by the complexity and fragmentation which it introduced.
Sustainability and Transformation Plans, now Partnerships, got off to a difficult start. There was limited time to forge relationships, develop plans collectively and make difficult decisions about changes to these local services. Financial pressure also led to STPs been viewed as a vehicle for cuts rather than as a way of making services work more effectively, undermining trust.
Since then, other organisational changes hoping better to align systems have joined the list. Even for those working in the NHS, the acronym spaghetti of health systems is confusing. Integrated care systems (ICSs), accountable care organisations (ACOs), and integrated care partnerships (ICPs).
But these do have the potential to unravel some of the wasteful aspects of the internal market and allow organisations to work together in the best interests of patients.
Perhaps in part because the term ACO shares a name with organisations in the US, fears have been expressed that this will lead to “Americanisation”. The truth is that proposed ACOs in England do not undermine the founding principles of the NHS, which are as important now as 70 years ago: that the NHS is free at the point of use, available to all, based on need and not the ability to pay.
The evidence to our inquiry was that ACOs, and other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite. But the debate has become toxic and is getting in the way of practical and necessary changes which the health service itself would like to see. ACOs should now be piloted and, if successful, established in legislation as NHS bodies. In reality, it is unlikely that private companies would bid for control of ACO contracts, but the war of words will continue to rage unless this is put beyond doubt that they will remain public bodies.
Any system or partnership will, however, struggle to make a difference without adequate funding. The recent uplift for NHS England is welcome but excludes public health, which is vital for reducing future demand and tackling health inequality. It also excludes training and professional development budgets which are essential to retaining as well as training the workforce. Most worryingly, it so far excludes social care, where there are high levels of unmet need. Social care is in a parlous state and this is seriously adding to avoidable harm for individuals as well as adding pressures and costs across the NHS.
The settlement for the NHS must earmark funds for transforming services. Changes to the way people work together often require upfront funding to get things started, including capital funding for facilities or technology.
Support for joining up services at local level is widespread across the health and care community. Integration may not save money and indeed in the short term, it may cost more by identifying unmet need. Success must be judged by whether it delivers a better experience for patients and those looking after them.
My view is that structural change must not become an end in itself and under no circumstances should we have a further major legislative upheaval. The legal barriers to joined-up working and the fragmentation that arose out of the Health and Social Care Act 2012 can be reduced. This should take place through a bottom-up approach, designed and led by the health and care community and patient representatives. If there is political will to listen to them, and to work with them to find agreement, revision of legislation is difficult but not impossible.
Government, NHS England and other national bodies must also do better at making the case for change. A clear narrative which explains in plain English, the purpose of any reforms and how these help patients is critical.
Dr Sarah Wollaston is MP for Totnes and chair of the Health and Social Care Committee
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