Reorganising the NHS
Future arrangements must support shifts in care
Cutting management costs by half will make it difficult for Integrated Care Boards (ICBs) to deliver on their core purposes. Narrowing their focus to strategic commissioning adds to the challenges, as does the likely merger of ICBs in some regions and the departure of experienced system leaders. ICBs are at risk becoming the fifth wheel on the coach.
The signals from ministers suggest they will look to NHS trusts, hospital groups and provider collaboratives to deliver improvements in care, offering high performing providers greater freedoms as a reward for delivery. Doing so may sharpen the focus on improving existing services but is unlikely to be sufficient in bringing about the three shifts that are expected to be at the heart of the 10 year plan to be published in June.
A countervailing force is needed to achieve these shifts and reverse the trend of acute services taking a rising proportion of the NHS budget despite plans to the contrary. ICBs are well placed to perform this function by building common cause with NHS and other partners to improve population health and transform care delivery using all available assets.
On the shift to prevention, much will hinge on whether ICBs can use partnerships with local authorities, the voluntary and community sectors and others to deliver the government’s key mission to improve health outcomes. NHS trusts can make a vital contribution to this work as anchor institutions in their communities and by using their expertise in prevention to support patients to stay healthy for as long as possible. Their role in rehabilitation is also important in enabling people to return to work.
ICBs will be expected to take the lead in the development of care closer to home by developing neighbourhood health services. The mixed record of commissioning in the NHS calls for a different approach this time around with less emphasis on transactional behaviours and a commitment to work with providers and others to put in place new care models. This means creating teams that bring together staff from different agencies to deliver joined up care for patients with specific needs and medical conditions.
There is hope in the part played by some providers in leading this work in the NHS and other health care systems. South Warwickshire’s frailty service is a leading example involving community staff working for the foundation trust supporting people in their own homes where appropriate. These staff work closely with colleagues in the hospital’s acute frailty unit and they enable patients who are assessed and treated there to return home as quickly and safely as possible. The ambulance service is closely involved in ensuring that patients are cared for in the right place.
The development of health pathways in the Canterbury Health Board in New Zealand is an example of general practices working more closely with hospital specialists and their teams to deliver benefits for patients. These pathways define how patients should be treated in the community and when they should be referred to hospital. They were developed initially by general practitioners and specialists and the closer relationships that resulted were key ingredients in delivering care differently. Other countries including Wales have adapted the health pathways approach to support the shift of care from hospitals to the community.
The Southcentral Foundation health system in Alaska shows how a neighbourhood health service contributed to more care being provided in the community. Serving around 65,000 Alaskan Native people, Southcentral underwent a major transformation in the 1990s and in so doing moved from being in crisis to becoming a high performing system. This entailed establishing multidisciplinary teams - including medical specialists - capable of providing most care needed by patients in the community with an emphasis on holistic person-centred care. Hospital use fell dramatically.
Nearer to home, a number of ICBs have made progress in integrating care in neighbourhoods and places in partnership with providers, local authorities and others. In Surrey, this involves the adoption of a health creation approach on a housing estate in Mertsham in which general practitioners listen to people living on the estate about what matters to them and working with them to find solutions.
Similar work is underway in Lancashire and South Cumbria’s primary care networks where the focus is on tackling inequalities and improving care delivery. A different example from West Yorkshire is work in the Wakefield place partnership that has reduced the use of hospital beds by offering a multiagency urgent community response service to adults identified as high risk of hospital admission.
All of these examples are a reminder that the benefits of integrated care are realised when barriers between health and care professionals are removed. Organisational integration and partnership working may support the emergence of new care models but only when this results in clinical and service integration do patients experience improved care. The value of involving people receiving care in the design and delivery of these models is also a common theme.
If ICBs are able to act on these lessons, they can use their role as system convenors to make a reality of the three shifts working with NHS providers and others. This includes giving staff the time and space to agree how best to use increasingly scarce resources for the benefit of patients. The fifth wheel can become the steering wheel with the right leadership and clarity of roles in delivering the new NHS plan.