It’s taken a long time for the public to come round to the idea that maybe, just maybe, the Tories aren’t out to get the NHS. Persuading people of that fact is arguably one of Boris Johnson’s great personal achievements as Conservative leader. True, the Tories are never likely to be seen as ‘the party of the NHS’ in the way Labour are, but perceptions have certainly come a fair way since the much-reviled Andrew Lansley reforms of the Coalition years.
Things have come so far, in fact, that the Government feels able to embark on the most significant top-down NHS reorganisation for a decade. The direction of travel is going to be very different to the Lansley reforms – in fact, the explicit aim is to roll many of them back – but the scale of the planned restructuring is such that it deserves to be scrutinised very carefully indeed. Particularly since the two people who agreed and devised the reforms, Matt Hancock and Simon Stevens, will no longer be around to see them through – and take any flak.
The Health and Care Bill has been pitched as a response to the Covid crisis. But in fact, the bulk of it is based on Stevens’ long-held ambition to integrate the NHS more effectively, and see competition replaced by collaboration as its driving force.
Already the NHS in England has been subdivided into 42 ‘Integrated Care System’ (ICS) regions, of which 13 are at a more advanced stage. But the Bill will go much further, not only giving all of these a legal basis, but making them the main bodies through which the NHS in England is run. Managed by an ‘Integrated Care Board’, overseen by an ‘Integrated Care Partnership’ and populated by a proliferation of joint NHS-local government committees under a shared ‘duty to collaborate’, each ICS will have as its raison d’être greater health and care integration.
The basic idea here is actually pretty appealing: everybody – GPs, hospitals, social care providers, local government, health charities – should be working closely together to meet patient needs, breaking down barriers between different institutional silos. This should smooth the flow of patients around the system, directing them to where they can get the most appropriate treatment or support, and (crucially) taking the strain off frontline workers on hospital wards. There’s also a population health element to integration, prioritising prevention over cure. The net result is supposed to be better health outcomes, delivered in a less resource-intensive way.
England isn’t the only place to have come up with this idea. Integration as a solution to the pressures of an ageing population has been tried in New Zealand, Spain, Sweden, Scotland and elsewhere.
However, the model developed by NHS England, promulgated through The NHS Long Term Plan in 2019, is based on surprisingly little evidence. Back in 2017, a National Audit Office report on health and care integration warned that:
‘Departments have not yet established a robust evidence base to show that integration leads to better outcomes for patients. The Departments have not tested integration at scale and are unable to show whether any success is both sustainable and attributable to integration.’
That is, in essence, still the case today. Ministers seem inclined to take the purported benefits of the ICS reforms largely on faith – perhaps because, unlike the Lansley reforms, they are the brainchild of NHS bosses, not the creation of politicians.
This is why I have spent the past few months evaluating the data emerging from the 13 pioneering ICS regions – most notably Greater Manchester, where integration is most advanced and the data is richest. And the picture is very far from encouraging.
As part of ‘Devo Manc’, Greater Manchester was the earliest region in England to integrate its care systems, taking charge of health and care for 2.8 million people from April 2016. If the ICS approach is going to work well anywhere, it should be somewhere like Greater Manchester: a densely populated, well-connected conurbation with a distinct regional identity, strong local political leadership and a good track record of healthcare organisations working together. More formalised integration was also smoothed by a chunky £450m ‘transformation fund’, the equivalent of 7.5% of the region’s £6 billion annual health and social care budget.
Despite these manifest advantages, the best that can be said is that results have been mostly quite poor. Take for instance ‘delayed transfers of care’, a key indicator used to gauge ‘bed-blocking’ at the interface between hospitals and social care. This was 65% higher on average in the years after integration (until just before the pandemic) compared to the years beforehand. In the ICS areas as a whole, this increased by 24% – compared to just 9% across the rest of England.
Before the pandemic struck, Greater Manchester was also falling short on the concrete targets it had set itself, for instance around mortality. There were supposed to be 580 fewer respiratory disease deaths by 2021, a drop of about 16%. In fact, by 2019, respiratory disease deaths were up by 7%. In 2016, there were seven more respiratory disease deaths per 100,000 people in Greater Manchester than in England as a whole. By 2019, this had doubled to 14 more.
It’s not just Greater Manchester where things don’t seem to have gone to plan. Other regions such as West Yorkshire have progressed the ICS model under the supervision of NHS England, rather than elected local leaders. But a preliminary survey (the data is more imperfect because formal integration started later) points to limited overall improvement at best. On bed-blocking, the region does well. But some other indicators – like emergency readmissions – have weakened. And however you slice it, there is no evidence, across either West Yorkshire or the 13 pilot areas more broadly, of the sort of large-scale improvements the ICS reforms are supposed to bring.
Given the scale and complexity of the Integrated Care Systems, it’s hard to pinpoint exactly why this is. But that complexity might itself be part of the answer. It’s notable that while both Greater Manchester and West Yorkshire saw their NHS workforces expand at a much faster rate than the national average in the four years before the pandemic, the proportion of clinically qualified NHS workers fell more quickly. Perhaps new integrated structures and processes are absorbing resources – personnel, time, energy and money – that could better be spent elsewhere.
Supporters of the ICS reforms will say that more time is needed: in 10 to 15 years, once reforms have bedded in, they will be transformational.
That’s all very well. But in the meantime, there are pressing problems facing the NHS, including a massive treatment backlog caused by the pandemic. Already waiting lists are at 5 million.
The Government’s determination to tackle the long-term problems facing health and care provision is to be welcomed. But it is important to take the time to get things right, rather than intensifying the current pressures on the NHS through costly and disruptive reforms that are not supported by national or regional data.
Our paper suggests that instead of rushing off down the road to deeper integration as per the ICS model, ministers should take a step back, pause to look at the data in more detail, and demand to see a more convincing evidence base for the approach proposed in the Health and Care Bill.
This would mean letting the 13 more advanced ICS regions carry on with integration for the next five years or so, while reserving judgement on whether the approach should be driven forward across the rest of England. In the meantime, ministers can focus on the more immediate pressures on the NHS, which are likely to build up as winter approaches.
If the ICS reforms eventually work out, the Conservative Party isn’t going to get the credit. But if they go wrong, it’s pretty clear who’s going to get the blame. The public might be prepared to forgive one Lansley-esque healthcare misadventure in a decade. They might not be so willing to forgive two.
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