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Integration in the NHS
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Making the NHS more joined-up. Obvious but how?
Looking from the outside, England has a national health service, a simple proposition whereby, funded through taxation, patients have access to the combination of GP surgeries, hospitals and district nurses they need to keep them well.
However, visitors from health systems overseas, and even residents of these shores looking more closely, are struck by the degree of fragmentation that exists in the NHS. Acute, community, mental health and ambulance trusts and charities all play separate roles and operate in separate geographies. As organisations they each own their own buildings, people and systems, and they must work hard to forge and maintain brand identity, staff loyalty, high standards of care and economic viability. GP practices are separate again, being locally-based and independent business partnerships. It would not be wholly wrong to say that the largest private hospital group in the UK, with its company-wide standards, systems and procurement, operates on more of a national health service model than the NHS.
Whilst a sense of local ownership of, and community involvement in, local institutions is important, this functional and geographic fragmentation of the NHS can get in the way of delivering high quality patient care affordably. Perhaps an extreme example, but a recent case of an old lady whose condition deteriorated on a Thursday and died on the Monday having been passed between nine different NHS-badged entities in between – her relatives’ complaint was a hard one to resolve. As for affordability, one can reasonably challenge the need for each organisation to own its infrastructure, but more importantly, with management teams focused on their separate bottom lines, affordability is rarely considered on a system-wide basis and opportunities to make big value-for-money improvements are lost.
It is not surprising, then, that much discussion during the Government’s recent listening exercise on health reform has turned on the subject of integration and a potential role for Monitor, as economic regulator, promoting it.
It is an attractive word to many, and more friendly than “competition”. But the question is, integration of what? And how far would a health system with more integration in it deliver better quality and value?
Berkeley recognises there are two broad categories of integration – one bringing a package of services together for a specific group of patients and their entire care, the other of organisations coming together.
The first category of integration is about improving significantly the quality of care for patients with a common condition, like diabetes, or for a population group, like the frail elderly. Having done a thorough analysis of health and care needs, a pathway or suite of services can be designed to achieve the best outcomes with a good patient experience, maximising prevention and self-management and minimising waste. The suite of services may extend across a number of different settings – home, primary and community, social care and acute and could be commissioned under a single contract with a prime contractor integrator, which could be an existing provider or a new entrant.
For patients, control would be enhanced and care better co-ordinated and safer. If the patient group targeted is a high consumer of healthcare resources, integration may achieve significant savings along with the improved quality.
So why not commission all healthcare in this way? First, the needs of individual patients are unique and, wherever you draw the scope of your integrated service, some patients will defy categorisation and those on the boundaries may receive a distinctly non-integrated service. Second, this kind of integration explicitly cuts across organisational boundaries and use of buildings, people and IT in their existing configurations may not work. The more integrated service models there are in operation, the less cost-effective existing infrastructure provision may become, and there may be a trade-off between the benefits of the integrated solution for one set of patients and the total cost-effectiveness of care for other patients. Ultimately, wholesale adoption of integration for defined patient population groups could result in fragmentation through a different route.
This brings us to the second category of integration – of two or more organisations coming together. There are several permutations of this form of integration, many of which are being enacted in today’s NHS. Some acute trusts are combining with neighbouring trusts through outright merger or a looser co-ordination of capacity and resource sharing. Prompted by Government policy, some community services trusts are merging into acute trusts, some into mental health trusts and one or two combining with local council social care organisations.
This form of integration can bring organisational benefits in terms of shared infrastructure and improved quality through building critical mass in clinical expertise. The removal of organisational barriers, can also provide a strong foundation for the introduction of the first category of integration.
However, in common with mergers and acquisitions in the private sector, organisational integration in the NHS is regularly transacted but not often followed through. When push comes to shove, local politicians, patients and staff are often reluctant to embrace the change necessary to complete the integration job and secure the potential benefits. Plus, this form of integration is a long haul, requiring sustained commitment from the boards and executives of all participating organisations and may not survive the regular churn in senior positions. Sometimes, looser collaboration may be a route which delivers good progress more quickly and may be a first step to tighter integration later.
So a fragmented NHS is far from optimal, and integration is not a silver bullet offering simple and repeatable solutions. Nonetheless, integration provides levers which like-minded and resourceful local leaders can pull selectively to achieve changes which both meet their organisational objectives and make obvious sense to those looking from outside.
Integration in the NHS