News analysis: Solving the integration puzzle

Even after a minor make-over, ditching its original accountable care branding, integrated care has had a big image problem lately. Back in 2014’s Five-year forward view, it was the widely supported goal for transformation efforts. But in recent months it has faced accusations of being a Trojan horse for privatisation and nothing more than a vehicle for cost-cutting. For health economies across the UK pursuing an integrated care agenda, the change of mood is perplexing and potentially distracting.

A Commons Health and Social Care Committee inquiry into integrated care, covering organisations, partnerships and systems, has provided a platform for some of the debate. But in reality, the inquiry responds to increasing concerns and campaigns that have led to judicial reviews of a proposed accountable care organisation contract.

The challenges have come as a surprise to many. There seemed to be complete agreement about the benefits of more integrated care. Last year’s forward view update promised to ‘make the biggest national move to integrated care of any major national western country’. It suggested sustainability and transformation partnerships would evolve into accountable care systems, with some of these moving on to become accountable care organisations over time. More recently, NHS England and NHS Improvement have dropped the accountable care terminology in response to some of the concerns, and now talk of developing integrated care systems.

The overriding aim of integrated care is to address fragmentation in service delivery and ensure services are built around patient and population needs. The King’s Fund defines integrated care as what happens ‘when NHS organisations work together to meet the needs of their local population’. This can involve local authorities and the third sector, and the most ambitious forms of integrated care aim to improve population health by tackling the causes of illness and the wider determinants of health. It identifies three forms of integrated care:

Integrated care systems (ICSs) have evolved from sustainability and transformation partnerships and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers, commissioners and local authorities.

Integrated care partnerships (ICPs) are alliances of NHS providers working together to deliver care. These include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.

Accountable care organisations (ACOs) are established when commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract.

It is this last format that has provoked recent concern. Two legal challenges have been launched – one questioning the legality of the ACOs under the Health and Social Care Act 2012, the other arguing that ACOs will lead to increased privatisation.

Integrated debate

At a breakfast briefing on integrated care at the end of March, King’s Fund chief executive Chris Ham challenged this. ‘We believe arguments that integrated care and accountable care will lead to increased privatisation are very wide of the mark,’ he said. Integrated care systems and partnerships are being led by the NHS in collaboration with other public-sector partners. And the two areas that have so far expressed an interest in using the proposed ACO contract – Manchester and Dudley – have both identified NHS trusts as their preferred providers.

While Professor Ham acknowledged private providers’ success in bidding for some NHS service contracts in recent years, he suggested they ‘don’t have the range of capabilities needed to take on an ACO contract and be able to deliver community services including primary care, some social care and some hospital-based services’.

He noted recent comments from David Hare, chief executive of the NHS Partner Network, that independent sector organisations were not expecting to be commissioned to take on ACO contracts in the immediate future – both because of the politics and the exposure to risk.

Also at the briefing, Graham Winyard, a former medical director for the NHS in England and a claimant in one of the ACO judicial reviews, likened the current move towards accountable care organisations to the private finance initiative. He said long-term PFI contracts had been a ‘catastrophic’ workaround to a chronic shortage of NHS capital in the 1990s. Similarly, he suggested that ACOs – ‘non-statutory bodies that can include private sector organisations as partners in long-term contracts’ – were the wrong way to tackle the service’s current fragmented structure.

He said the lack of open consultation on such a major change had led to ‘deep suspicion’. He was an ‘enthusiast for a single organisation to take most of the decisions about health and care for a defined population’ but this should be based on the former district health authority model responsible for commissioning and providing.

‘We would be moving to an NHS where most of the decisions that matter to the public will be taken by non-statutory bodies that can include private and commercial partners whose priority will be profit, not public service,’ he said.

Dr Winyard said he took little comfort from the fact that the first two proposed ACOs were being taken forward with NHS partners. ‘This policy will roll forward in all sorts of different ways,’ he said.

Paul Maubach, chief executive of Dudley and Walsall Clinical Commissioning Groups, is leading the development of the Dudley Multispecialty Community Provider (MCP) that will potentially use the proposed ACO contract. He argued that everyone agreed about the need for more integrated care to meet the changing needs of a population with higher levels of long-term conditions and multiple co-morbidities. ‘You can’t achieve better continuity and co-ordination or better long-term population management unless you design services around the person and the population, and that is why we want to deliver better integrated care,’ he said.

Dudley’s wide-ranging partnership has been in place for some time, with multidisciplinary teams delivering ‘staggering results’, reducing reported levels of social isolation and improving patients’ confidence in the management of their conditions. ‘We are already delivering better outcomes and better care for our populations, so why do we need to go the step further?’ Mr Maubach asked. ‘Well, if integrated care is the right thing to do, why wouldn’t you want to do it to deliver its maximum potential benefit for our population and staff?

‘We see a single integrated care organisation supported by a single population outcome-based contract as really important,’ he said.

Improving outcomes was complex requiring multiple factors to be addressed, he added. The MCP’s ambitions included improving healthy life expectancy by 1.5 years over five years for the population as a whole – but this demanded the maximum level of integration for its systems and ways of working, he said.

Mr Maubach highlighted general practice as crucial to the success of more integrated care, but it had to be more sustainable. GPs should be leading multidisciplinary integrated teams with the right level of support – the ACO contract offered the opportunity to deliver this. He said a flexible approach would enable GPs to be partially or fully integrated and would place general practice at the heart of the change.

Current commissioning approaches worked against integrated care, Mr Maubach added. In diabetic care, for example, GPs work to an outcomes framework, but when patients see diabetologists in acute settings, the hospitals are paid on the basis of activity, not outcomes. He said the lack of alignment was ‘nonsense’.

Back at the Health and Social Care Committee, NHS England chief executive Simon Stevens also had to address the privatisation accusation. He stressed that the specific ACO model was unlikely to be adopted by many areas as they pursue different models of integrated care. But he dismissed the privatisation concerns as scare stories, citing similar arguments over the years over the introduction of dedicated commissioners and the establishment of foundation trusts.

The Health and Social Care Committee had itself called for more integrated care in earlier reports, he added. In light of this, it will be interesting to read the committee’s conclusions after this inquiry as it has the potential to lead public opinion on the issue.

For the time being, the debate continues. Integrated care – delivered in various different models – remains a clear strategic goal. And the continuing suspicion around the policy does not provide the perfect environment for local health economies to develop their plans and engage with their communities.