Governments urged to rethink integration approach

As the NHS in England gears up to introduce formal integrated care systems – subject to the passage of the Health and Care Bill – and the other nations pursuing ever-closer collaboration, the trust said there was limited evidence that patient experience, quality of services, or delivery of out-of-hospital care have improved.

It warned that without concurrent investment in social care and broader public services to address the wider determinants of health, it was unlikely the latest reforms would deliver ministers’ hoped-for improvements.

The trust’s report, Integrating health and social care, said past attempts to increase integration had failed to overcome barriers to joint working, and had failed to provide the resources, infrastructure, or staff needed to meaningfully combine the services and move more care out of hospital.

There was limited evidence that pooling budgets had led to savings, though this should not be the primary goal of integration, the trust added. Restrictions on funding in the wider public sector have limited the impact of collaboration – investment in housing and education, which play a role in wellbeing, has declined, for example.

Though taking a different overall approach, the report said each UK nation has tried to improve integrated care delivery by changing the way services are planned, financed, and commissioned in the hope that more co-ordinated service delivery will naturally follow. But policymakers must move their focus away from organisational and structural reform, it added. Instead, they should prioritise the behaviours, incentives, skills and resources needed to integrate services at the front line.

Nuffield Trust senior fellow Sarah Reed (pictured), who co-authored the report, said 20 years of similar reforms across the UK had translated into only modest improvements, despite significant contextual differences in each country. This raised questions on what integration can achieve.

She continued: ‘Part of the explanation may be that policymakers have continuously fallen back on the same financial and structural levers to encourage integration, including short-term funding pilots, setting up joint boards and committees, and pooling budgets. 

'Often these initiatives have failed to learn from or build on the efforts that came before it, or address the broader culture, incentives, and infrastructure needed to make integration work. 

‘There is also only so much integration is likely to achieve while there remains a significant mismatch in the funding and staffing available across health and social care.’

Broader factors affecting the ability to be healthy and live independently will also limit the impact of integration on population health, she added. These challenges require long-term solutions and a focus on users' experiences. They cannot be solved just by integrating services.

Miriam Deakin, director of policy and strategy at NHS Providers, agreed that structural solutions will not provide the answer alone, and that behaviours and relationships form the basis for collaborative working

She added: ‘Alongside a focus on integration with the NHS, there remains a need for tangible, fully funded measures to improve pay and to tackle high vacancy levels in the social care workforce, to support the provider market, and to increase access and improve quality of care.

‘We know that without this, it will be difficult for systems to make the progress they want to make on improving outcomes for their populations, including reducing health inequalities.’