Rising demand for care, budget shortfalls and workforce shortages have put significant strain on UK health care providers and health systems in recent years. An important part of the government’s response has been an ambition to improve the coordination of care, patient care and patient experience, and shift resources to achieve better health outcomes.
In 2014, NHS England launched the ‘new care models’ to pilot new ways of delivering more coordinated care. With funding from the Health Foundation and in collaboration with health care providers, experts and policymakers in England, our team at the Duke-Margolis Center for Health Policy in the USA undertook a 2-year study of the progress and challenges in these integrated care models.
Our research found strong commitment from local and national leaders to transform health systems. Using our accountable care framework, we conducted interviews with providers and policymakers to identify gaps and areas for improvement. Although several factors are complicating progress – tight budgets, pressure to meet performance targets and conflicting or unclear regulatory requirements – NHS providers are developing the tools and competencies to deliver better integrated care.
In our new report, Advancing Integrated Care in England: A Practical Path for Care Transformation, we describe how local areas can create a ‘care system integrator’ to develop the infrastructure needed to implement care reforms, given current resource constraints. The care system integrator is a locally rooted entity for convening, coordinating and supporting existing networks around population health goals. The report highlights regions already implementing care-system-integrator functions, describing the challenges and identifying steps NHS England can take to support its national care integration goals.
A focus on function, not form
The care system integrator is an entity that can coordinate across multisector providers – medical and non-medical – to support the delivery of more effective and affordable care. Instead of replacing existing providers and systems, or trying to achieve reforms without supporting resources or organisational structures, the integrator identifies resources to enhance local capacities, arrangements and networks.
Communities have taken different approaches to implementing the functions of the care system integrator. Essex Health and Wellbeing Board linked together three Sustainable Transformation Partnerships (STPs) using the nationally mandated Better Care Fund to pool resources for health and social care. West Yorkshire and Harrogate convened all six commissioning bodies to develop a unified strategy for complex care management. Although starting points differed, the approach remained the same: convening entities to identify and work towards discrete goals on behalf of defined populations.
Given limited resources, local systems can focus on incremental delivery changes motivated by a shared vision to yield compounding results over time. In the case of Cambridgeshire and Peterborough Foundation Trust, the decision to invest in team-based care led to the creation of ‘neighbourhood care teams’. The gradual growth in pooled budgeting through the Better Care Fund also helped stakeholders across the Cambridgeshire and Peterborough region to develop a jointly governed Integrated Commissioning Board, demonstrating the evolution of partnerships for population health over time. Other regions might build their integrator capabilities by working together on initial coordination priorities. Wakefield, for instance, tackled loneliness and fragmentation of care by aligning each care home with a GP practice, embedding pharmacies and expanding primary care hours, and setting measurable goals for care improvement.
Reframing top-down policies to enable bottom-up innovation
Policymakers can accelerate these efforts by aligning regulations to support integrated care capabilities at the regional and local level. While the NHS has provided resources to guide care models in this transition, scaling and sustaining reforms will require additional steps. We make recommendations for policymakers to better support a care system integrator function and better equip organisations to achieve better population health.
For instance, policymakers should clarify the goals and elements of reforms, creating a common narrative around specific population-health improvement targets that better connect providers and policymakers. The NHS should improve communication and alignment across policymakers, regulators and providers and prioritise evaluation and data analysis. By tracking measures early on, policymakers can identify which new models should be implemented more widely. National initiatives, such as NHS England and the Health Foundation’s Improvement Analytics Unit, could support these efforts through rapid-cycle evaluations.
Converting pilots into practice
The experiences of England’s integrated care pilots demonstrate that it’s possible to align systems and services around population health goals, despite the challenges. The journey, however, is hampered by limited capital and resources. Policymakers need to deepen the commitments articulated in the Five Year Forward View for the NHS in England and boost assistance for local pilots to help care integration achieve scale across the country. Our recommendations provide practical and realistic steps for reducing fragmentation in English health care so that NHS England can achieve its goal of providing high quality, affordable and increasingly integrated care.
This blog was co-authored by Kushal Kadakia, Research Assitant at the Duke-Margolis Center for Health Policy, Andrea Thoumi, Research Director at the Duke-Margolis Center for Health Policy and Assistant Director at the Global Health Innovation Center, Krishna Udayakumar, Director of the Global Health Innovation Center, and Mark McClellan, Director of the Duke-Margolis Center for Health Policy.
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