Integrated care is something of a holy grail for the NHS. It breaks down the barriers between GP surgeries and hospitals to ensure patients are seen by the best type of clinician at the best time in the best place. It also has the potential to save money by increasing efficiency – an attractive proposition in the current economic climate.
Take diabetes care, for example. When not managed properly it can lead to heart disease, eye problems, kidney disease and even amputation. A project in Manchester has shown how complications can be reduced by bringing secondary care expertise into the community. By giving nurses immediate access to consultants through virtual clinics, and introducing structured patient education programmes, they have shown it possible to reduce the risk of complications and save the NHS money.
There are two main elements of the reforms that make the delivery of integrated care more difficult. The first is the emphasis on strengthening ‘market forces’ to shape health services. Even without the Health and Social Care Bill, the Government’s new policy of ‘any qualified provider’ will encourage the involvement of a much wider number of health care providers, including private sector organisations, creating competition with existing NHS providers for specific services within care pathways. Increased competition for these service areas could easily lead to cherry picking of the easiest and most lucrative contracts, leaving it to the NHS to pick up the more complex service areas, as well as making it harder for providers to co-operate and collaborate across the whole pathway for the benefit of patients.
The second problem with the reforms is their complexity. They were launched on a promise to reduce bureaucracy but now look ridiculously complicated. Integration of healthcare depends on getting all the different parts of the NHS working together. If this was difficult in a world of strategic health authorities and primary care trusts, how much more difficult will it become with an NHS Commissioning Board, clinical senates, clinical networks, Public Health England, Healthwatch England, Health Education England, citizens’ panels, local education and training boards, health and wellbeing boards and clinical commissioning groups?
The Government made a significant concession on the issue of integration in response to the BMA’s lobbying – changing the primary role of Monitor from promoting competition to requiring the regulator to support the delivery of integrated care. But, of course, this isn’t always going to sit easily with other requirements on commissioners, for example to extend patient choice of provider across a much greater range of services. Whatever happens on the Bill, clinicians must take the opportunity to make sure that better integration of care does become the primary driver for change in local health economies, not the enforcement of an ideological obsession with increasing competition.
As the Health and Social Care Bill moves into the House of Lords, the debates will continue. We have little time left for persuasion. If we are going to win the integration debate, we must illustrate our arguments with examples about how patients will be affected by the reforms. If you are working on a project involving integrated care that you think will be jeopardised by the reforms, email us at firstname.lastname@example.org or leave a comment below.