As the Health and Care Bill proceeds through the Committee stage, belated critiques and assessments have begun to appear flagging up serious questions over the effectiveness of the emerging system of Integrated Care Systems (ICSs).
One traditionally right wing think tank, the Centre for Policy Studies (which boasts on its website that it was “founded in 1974 by Sir Keith Joseph and Margaret Thatcher and was responsible for developing the bulk of the policy agenda that became known as Thatcherism”) has published a report questioning the evidence that “integrated care” can deliver any improvement in outcomes for patients.
Perhaps this is not such a great surprise, since the Health and Care Bill proposes to establish 42 statutory ICSs by scrapping one of the core sections (Section 75) of Andrew Lansley’s hugely controversial Health and Social Care Act, which followed in the tradition of Thatcherism by entrenching competition and a competitive market in the NHS.
However the CPS report does appear as disenchanted with the Lansley reforms as it is with the latest government attempts to unpick them. Its author, Karl Williams, notes that the latest changes, as with almost every previous reorganisation of the NHS, appear to have been embraced uncritically by all and sundry:
“the alarming truth is that, as with the Lansley reforms, this seismic reform of how the NHS works has had surprisingly little scrutiny. To put it bluntly, everyone is in such fervent agreement that the ICS model of integration and collaboration is the future of the NHS that hardly anyone appears to have looked properly at whether this approach works in practice.”
Williams points out that four years ago the National Audit Office warned of the lack of evidence to show integrated care could deliver the promised improvements in patient care – and that there still is vanishingly little evidence – if any – to prove it can.
Perhaps surprisingly given its ideological approach, the report draws on some serious and evidence-based research into the performance since 2016 of the 13 early implementers of the ICS model, with a particular focus on two of the largest – Greater Manchester and West Yorkshire and Harrogate. 2016 was when the notion of “integration” was first systematically raised by Sustainability and Transformation Plans, which have since morphed into ICSs.
Williams focuses on Delayed Transfers of Care (DtoCs), numbers of which patients medically fit enough to be moved from acute hospital bed to a care home or to their own home with sufficient support remain marooned in hospital. This is one of the areas where “integrated care” between the NHS and social care is supposed to improve performance, but the figures suggest otherwise:
“DtoCs across England as a whole were 14% higher in 2016-2020 than in 2012-2016. However, in in STP/ICS areas, the increase was 24% (when weighted for population).
“In other words, across the 13 early movers, delayed transfers of care (DtoC) increased by 70% more than the national average, resulting in over 80,000 extra hospital bed-days across a four-year period.”
In fact the figures show an above England average increase in seven of the 13 early ICS areas, ranging from a 17% increase in Suffolk and NE Essex to a massive 111% increase in Gloucestershire, with Greater Manchester on 65%, while six were below England average, with West Yorkshire showing no increase and Nottingham & Nottinghamshire achieving a 7% reduction.
On each of the measures different areas appear at the top and bottom of the comparisons, suggesting that there is no coherent pattern of success or failure. West Yorkshire and Greater Manchester are both found to have four “firm failures,” in the comparison of outcomes, but only one shared failure – the reduced percentage of the workforce with clinical qualifications. Greater Manchester also shows failures on DtoCs, respiratory disease mortality, neonatal outcomes, while West Yorkshire’s problems are with emergency readmissions, mental health and admissions linked to alcohol.
Only on levels of attendance at A&E do most ICSs show an overall improvement on the England average, although even here five ICSs are worse than average, the weakest being Dorset.
Williams sums up:
“… the evidence above does not suggest that the ICS model has been a disaster. But it definitely shows that it is not a panacea: in particular ICS status appears far less significant in determining healthcare outcomes than other factors, including how well or how badly the trusts in question are managed.” (page 78)
He goes on to warn that ICS structures face the danger of becoming bureaucratised, that accountability mechanisms are “poorly defined,” that ICBs “could actually cement the dominance of secondary care,” and as we might expect from a Thatcherite think tank, raises fears that:
“While the purchaser/provider split in the NHS is being kept in theory, in practice it looks likely to be greatly diluted.”
More significantly he also warns of the likely cost of establishing ICSs:
“Even semi-effective implementation of the ICS reforms in their current form is likely to be costly. The GMHSCP received a one-off sum of £450m (equating to 7.5% of the region’s annual health and social care budget) to help in its transformation into an ICS …. If each of the 29 ICSs established since the first two ICS waves were to receive similar funding, the Government would need to find about £7 billion.”
Williams’ major recommendation is to drop the Health and Care Bill’s proposed legislation to establish ICSs on a statutory basis, and hold back on such action, allowing the 13 ICS pilot schemes to run for FIVE YEARS … “until around 2026”:
“If outcomes data for the 13 ICSs unexpectedly show significant improvement, then the newer 29 ICSs can accelerate down this path of integration, using best practices tested and refined by the pioneers.”
Meanwhile a very different approach can be seen in the Department for Health and Social Care’s 54-page Impact Assessment of “Core Measures” in the Bill, which effectively brushes aside any potential costs, and makes no reference to the levels of additional funding which Williams assumes to be required to establish ICSs.
It does admit that “there is mixed evidence on whether collaboration can provide cost savings in the delivery of services,” but claims there is consensus that “collaboration between health and care organisations and the reduction of siloed working can and should go further.” (p9)
The Impact Assessment (IA) is specifically only addressing the Bill’s proposals linked to NHS England’s Long Perm Plan. It timidly distances the government from the disasters of the 2012 Lansley reforms pushed through by the Tory-Lib Dem coalition, noting that while “The 2012 Act was designed in part to drive value by raising the importance of commissioning and competition in the system,” subsequent experience showed that “improvements envisaged as flowing from this approach did not materialise to the extent that was hoped.” (p8)
Noting that the Bill brings an end to the pretence of GP-led commissioning, the IA admits:
“… a NIHR research programme between 2014 and 2018 did not find clear evidence that the involvement of local clinicians in the commissioning of acute hospital services provides health benefits.”
The IA goes on to stress the costs and delays that are involved in competitive tendering, making the case for the repeal of Section 75 of the 2012 Act, although two of the three scenarios discussing the likely situation under NHS England’s proposed Provider Selection Regime assume that contracts would be awarded or rolled over without competition to a private provider. (p35-36)
The IA underlines the fact that the Bill does not prevent and could facilitate additional outsourcing and privatisation:
“Competitive tendering will allow decision making bodies to test the market when this provides an opportunity to add value for patients, taxpayers, and population without generating adverse impacts …. This in turn will provide businesses with opportunities to enter the market and work alongside decision making bodies to contribute to these objectives.” (p36)
A third major assessment of the Bill has come from the once left of centre IPPR (“The Progressive Policy Think Tank”), who have published a new report Solving the Puzzle – Delivering on the promise of Integration in Health and Care, by Parth Patel.
This report is also based on some potentially useful research, focusing on the inequalities between the 42 ICS areas, after working with management consultants Carnall Farrar to develop an “integrated care index” to enable comparisons to be made. But frustratingly it gives us only a few bullet point glimpses of the full findings.
It appears to show patterns of inequality that are as inconsistent as those found by the CPS report.
So for example there are almost nine times more delayed discharges per 1,000 bed days in Norfolk and Waveney ICS than there are in Sussex and East Surrey ICS. But conversely the rate of maternal deaths is 16 times higher in Sussex and East Surrey than in Suffolk and North East Essex.
People with severe or complicated mental health problems in Bath and Northeast Somerset, Swindon and Wiltshire ICS are three times more likely to have a care coordinator than those in Leicester, Leicestershire and Rutland ICS.
Children with a mental health emergency in Birmingham and Solihull ICS are 80 per cent more likely to be seen by a mental health specialist within four weeks compared to children in Gloucestershire ICS.
Patients in North London ICS are 81 per cent more likely to say they lack access to sufficient support from local health and care services compared to patients in Dorset ICS.
In typical IPPR style the report includes plenty of hypothetical situations:
“If the current reforms are successful, each ICS should show an improvement in our integrated care index. That will only happen if the government matches its reforms with a plan to provide ICSs with the resources and capabilities they need to deliver improvement.” (p9)
But we already know from government funding announcements (and now from the Impact Assessment, which makes no reference to any increases in funding) that there will be no extra resources to match the reforms: so it’s fair to conclude that the ICSs WILL FAIL to deliver the promised improvements, and the levels of inequality will remain at least the same or widen.
In equally pointless speculation Patel concludes that if all the new 42 regions matched the performance seen in the top 25 per cent it would mean 42,600 more bed days available in the NHS because of fewer delayed discharges. That’s a pretty big “if”.
However the IPPR report is not entirely without value. Under ‘Building a Culture of Collaboration’ it makes proposals that include “ICS members should have the power to democratically remove their chair.” (p12)
It also proposes “Limiting legislative proposals to give the secretary of state greater powers of direction over NHS England and local service reconfigurations,” (p15) and calls for “A ‘Long Term Plan’ to overhaul the quality of social care,” (p15) arguing the obvious point that that “Better integration with the NHS will remain challenging without improving the employment conditions of care workers and without improving the quality of social care providers.” And it proposes patients should be represented on each ICB. (p21)
Overall both IPPR and CPS reports underline concerns that the case for a complex top-down reform to impose “integrated care” is less than convincing, and that the legislation itself is contradictory in boosting central powers while apparently seeking to devolve more decision-making. Both reveal the need for extensive amendments to minimise the damage of a deeply flawed Bill.
Both reports emphasise that any positive change in patient outcomes is dependent upon more resources to address weaknesses – while the DHSC’s Impact Assessment makes clear no such resources are coming.
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