The National Policy Context

The context for delivery of care within the NHS over the next 3-5 years aims to deliver a very different patient experience from the current situation.

The Department of Health’s Choice Framework, published in April 2016 but updated in January 2020), set out a goal of ‘giving patients greater choice and control over how they receive their healthcare’, and of ‘empowering patients to shape and manage their own health and care’ [1]. This aim sits alongside that of NHS England’s Five Year Forward plan for integration of care with a recognition that ‘making progress … cannot be done without genuine involvement of patients and communities’ [2].

Integrated care is a national goal which recognises that continuing to achieve greater efficiency savings from the NHS is not the only answer. Following publication in 2014 of the Five Year Forward View by NHS England, every part of the country developed sustainability and transformation plans (STPs), which are described in the update published in 2017 [2] as “pragmatic vehicles for enabling health and care organisations within an area to chart their own way to keeping people healthier for longer, improving care, reducing health inequalities and managing their money, working jointly on behalf of the people they serve”.

The Five Year Forward View update also states: “Our aim is to use the next several years to make the biggest national move to integrated care of any major western country,” [2]. This aim is being taken forward through different forms of partnership arrangements that are emerging in different places with various labels being used for each type.

The King’s Fund says that since April 2021, all parts of England have been covered by one of 42 integrated care systems (ICSs) [3]. The central aim of ICSs is to integrate care across different organisations and settings, joining up hospital and community-based services, physical and mental health, and health and social care. ICSs are part of a fundamental shift in the way the health and care system is organised. Following several decades during which the emphasis was on organisational autonomy, competition and the separation of commissioners and providers, ICSs depend instead on collaboration and a focus on places and local populations as the driving forces for improvement. They have grown out of STPs and are expected to be put onto a statutory footing from 2022.

With no statutory basis for ICSs, these voluntary partnerships rest on the willingness and commitment of local organisations and leaders to work collaboratively. The King’s Fund believes that the case for collaborative working in the health and care system has been strengthened by the experience of the Covid-19 pandemic, as the response has rested on different parts of the system working together to address the public health emergency, enable continued provision of essential services and to support people to remain well in their communities. Many health and care leaders emerged from the initial stages of the pandemic with renewed conviction about the benefits of collaboration and a determination to keep hold of and build on the progress made [3].

Among the objectives for these bodies – those charged with ‘joined up, better co-ordinated care’ – are horizontal and vertical integration, with the challenges of:

Demonstrating how provider organisations will operate on a horizontally integrated basis, for example, through clinical networks.
Demonstrating how provider organisations will simultaneously operate as a vertically integrated care system, connecting hospitals with GP practices and local community services.

NHS England’s offer includes: “The ability for the local commissioners […] to have delegated decision rights in respect of commissioning of primary care and specialised services,” [4].

The development of these partnership working arrangements is at an early stage and much work needs to be done to realise the benefits for patients and the wider populations, for which they are responsible. The importance of clinicians being at the centre of integrated provision and recognition of the time it takes to build collaborative working relationships are among the challenges identified by the King’s Fund:

The importance of local leaders investing time and effort in building trust and collaborative relationships and overcoming competitive behaviours that in the past have created barriers to partnership working.
The need for clinicians to be at the heart of integrated care developments, building on the work of the new care models and recognising the principal benefits of integrated care results from clinical integration rather than organisational integration.

“Engaging with communities and citizens in new ways, involving them directly in decisions about the future of health and care services,” is an aim set out in the Five Year Forward plan that provides a platform for engaging people with haemophilia, their families and carers in the development of integrated provision.

This drive for integration is mirrored in the specialised services commissioning intentions, which outline the strategic intention to improve the way specialised services are commissioned and contracted, reviewed and transformed. NHS England states that “Achieving our ambition will require changes in how services are commissioned and provided, with specialised care as a fundamental part of more integrated care for patients.”

In 2018/19, £17.2 billion was spent on specialised services. The level of funding for these services has risen more rapidly compared to other parts of the NHS, but it is still under pressure. The number of patients needing specialised services is rising due to an ageing population and advances in medical technology [4].

References

1. Department of Health & Social Care. The NHS Choice Framework: what choices are available to me in the NHS? (Updated 14 January 2020). Available at https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choice-framework-what-choices-are-available-to-me-in-the-nhs (accessed 23 June 2021).

2. NHS England. Next steps on the NHS Five Year Forward view. March 2017 (updated 2019). Available at https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/ (accessed 23 June 2021).

3. The King’s Fund. Integrated care systems explained: making sense of systems, places and neighbourhoods. May2021. Available at https://www.kingsfund.org.uk/publications/integrated-care-systems-explained (accessed 23 June 2021).

4. NHS England. Specialised Services. https://www.england.nhs.uk/commissioning/spec-services/ (accessed 23 June 2021)