Can the English NHS enter a 'period of calm' if it wishes to introduce integrated care?

Sir David Nicholson, KCB, CBE, is Chief Executive of NHS England.

In 2010 Nicholson jokingly described NHS reform plans, the implementation of the Health and Social Care Act (2012), as the biggest change management programme in the world – the only one “so large that you can actually see it from space.”

Andy Burnham MP gave a speech to The King’s Fund on 24 January 2013, entitled “‘Whole-Person Care’ A One Nation approach to health and care for the 21st Century”.

And the Conservative Party, with Jeremy Hunt MP as Secretary of State for Health, have been eyeing up ‘integration‘ too.

So, like many areas of policy such as the private finance initiative, personal budgets or ‘efficiency savings’, there might be considerable consensus amongst the main political parties about implementing a further transformational change in the English NHS.

In that famous King’s Fund speech, Burnham comments, “Second, our fragile NHS has no capacity for further top-down reorganisation, having been ground down by the current round. I know that any changes must be delivered through the organisations and structures we inherit in 2015. ”

This is coupled with, “While we retain the organisations, we will repeal the Health and Social Care Act 2012 and the rules of the market.”

The Health and Social Care Act (2012) as a legislative instrument, whatever the political bluster, had three main legislative aims.

It aimed to implement competitive tendering in procurement as the default option, thus expediting transfer of resources from the public sector to the private sector; it beefed up the powers of the economic regulator (“Monitor”) for this “market”; and it produced a preliminary mechanism for the managed decline of financially unviable entities in the NHS.

Therefore repealing the Act can be argued as a necessary and proportionate move for taking out the ‘competition jet engines’ of the NHS “market”.

Experience from a number of jurisdictions provides that the legal challenges in allowing integration (and bundling) within the framework of competition law are formidable.

There is a clinical case for integrated care, in allowing more co-ordinated care of the person across various disciplines, for example medical, psychiatric or social, for both health and disease.

If community services are ‘wired up’ with hospital services, provided that community services are not starved of money at the same time as hospital services, there is a good rationale in that the health of certain people, followed closely in the community, might not freefall so badly that they require admission to a medical admissions unit.

There is also a financial argument that integrated or whole person care might work, but clearly no political party will wish to prioritise this ahead of quality of clinical care, particularly given the current tinderbox of cuts in medical and social care.

But whichever way you look at it, ‘whole person’ care involves a huge cultural change; this has repercussions for how all professions conduct themselves in their care, especially with regards to community care, and has consequences for training of staff in NHS England.

And it is impossible to think that, whichever political party ultimately becomes responsible for introducing a whole person or integrated care approach, it won’t cost money.

For example, setting up the infrastructure for data sharing, whether clinical or for the purposes of unified budgets, has a long history of being expensive.

Estimates of the cost of the reorganisation just gone are a bit confused, but they tend to range between £2.5 and £3 bn.

The risk of turbulence can be, to some extent, mitigated against by known people at the helm, such as Andy Burnham or Liz Kendall, but the last thing the general public will wish is another period of massive upheaval.

It can be argued that these changes are ‘a good idea’, and it’s only a question of explaining the benefits to the general public, but, following the Health and Social Care Act and caredata, the track record of this current Government is nothing to write home about.

Twitter: @legalaware

Neil Chadborn

The challenge is that, with the same consultancy firms ‘supporting’ integration programmes in many parts of the country, we can expect the same outcomes – £ spent, but not much to show. In turn these management consultant-led programmes will expect huge efficiencies (I.e. £ cuts) and reductions in emergency hospital admissions. Unfortunately, there is no credible evidence that integrated care can achieve either of these. See Nuffield analysis showing no decrease in admissions comparing many English pilots with control patient data.

I think it’s best to focus on improving patient experience and quality of care. This may lead to efficiency savings, years in the future, but the case should be made as an investment in the NHS, social care and third sector, rather than an opportunity for management consultants and private companies.
http://legal-aware.org/ Shibley Rahman

Excellent comment – many thanks Neil.
http://chrysmuirheadblogs.wordpress.com Chrys Muirhead

I’m thinking that the Scottish situation re health and social care integration will have similar challenges but can only be a good thing in the longer term if it means patients, service users and carers will be better off. It’s the shorter time that will test the mettle, I think, of both sides in services as they try to combine systems, electronically and human resource wise. And the customers who will be at the sharp edge.
http://gravatar.com/rotzeichen Mervyn Hyde

Why do I feel a sense of unease when I hear Andy Burnham speaking to an organisation like the Kings Fund? http://www.kingsfund.org.uk/about-us/working-with-businesses

Please excuse me for being a dinosaur but I see no place for Business in the NHS.

I further believe that Andy Burnham will use his integrated health care platform to use the NHS for commissioning of private service companies.

This whole nonsense is just an expensive cover to use local authorities and the NHS as outsourcing organisations which will feed tax payers money into private sector profit.

I repeat what I have said in the past, our NHS was the finest health system in the entire world, Mckinsey the Governments advisers referenced a table produced by OECD, which showed we were the most cost effective health service in the industrialised world.

Why when we are at the top of the league would we go to the bottom to learn anything other than to make rich people richer through making profit out of sick people.

If Andy Burnham was genuine, not forgetting he helped break up the NHS in bite size trusts, ready for privatisation, he would be talking in terms of stabilisation and the rolling back of the private sector, until I hear language of that nature, I will distrust him and all of New Labour.
http://www,BritishAcademyofWesternMedicalAcupuncture George Nieman

As I have said many times before the only sure way to improve the NHS is to have medical/nursing and other practitioners taking over the organisation in each and every hospital. In addition we will need the services of financial advisors etc but the only people who really know the requirements for patients care are those I have mentioned. We have seen the poor judgements of so many Trusts due to administrators who no nothing about caring for the people who matter—the patients.

Can the English NHS enter a ‘period of calm’ if it wishes to introduce integrated care?