Part one: Introduction
Published 15 June 2016
It is almost two years since the publication of the NHS Five Year Forward View (5YFV), which has the aim of transforming health and social care in England, creating a truly integrated wellbeing service – shaped by and responsive to – local needs, and driven by smart population data dictating an overarching set of broad health outcomes.
Given the size and complexity of the NHS in England, its Chief Executive, Simon Stevens, has made it clear that he welcomes local solutions to the complexities of regulatory requirements, contracting, payment regulations and other factors that could inhibit or delay effective integration.
But signs are that progress is tentative, where even the most advanced parts of England pioneering new approaches to integration are moving slowly. New relationships take time to be established across organisations with different governance structures and regulatory regimes. New models of care need tests and trials which may throw up failures as well as successes. And then it takes time to disseminate and share knowledge.
Chris Hopson, Chief Executive of NHS Providers, which represents acute, mental health and community providers, says that a small minority of trusts are well advanced in developing and testing new care models.
“Some 10% are moving to integration pretty fast, another 30% are getting seriously interested and the rest are frankly struggling for a number of reasons – the most common being the actual day job of trying to provide services,” he told DAC Beachcroft.
In doing that day job, trusts are running up massive deficits to cover locum costs – significantly as a result of the Francis Review which has set tough staffing levels. The concerns around failing a Care Quality Commission (CQC) inspection on these grounds means almost every trust in England is in the red, with official figures revealing that NHS trusts ended the last financial year a record £2.45 billion in deficit. Meanwhile, trusts are also desperately trying to meet the £22 billion efficiencies target.
Add in the destabilisation caused by the junior doctors’ contract dispute, a shortage of some 50,000 clinicians, according to a report by the House of Commons Public Accounts Committee in May, a crisis in GP recruitment and retention, and the potential for further industrial strife in response to government plans to drop student nurse bursaries and introduce loans.
Anne Crofts, a Partner at DAC Beachcroft, says regulatory changes will also potentially impact on the pace and shape of integration. The new regulatory landscape will comprise the CQC, which has come under criticism for penalising trusts for not hitting tough post-Francis staffing quotas, working beside NHS Improvement – the merged Monitor and the Trust Development Authority.
“A key question is how NHS Improvement and the CQC will approach the regulation of integrated services, where responsibility for delivering care pathways will be shared by multiple providers under a single contract with commissioners. Will the regulatory burden be increased or simplified as a result?”
Much is being made of smarter use of data, integrated care records and data sharing to draw a more accurate map of local health needs for commissioners and to enable providers to provide better, more joined up care. Patients also increasingly expect to have online access to their records.
But sharing data between organisations can be “fraught with pitfalls if people don’t recognise and respect the legal safeguards, including the absolute necessity to communicate effectively with patients about how their data will be used and by whom,” says Crofts.
Where decisions are being made based on shared data, Crofts says that people also want to be assured that it is accurate and reliable. “One example is the Carter report [Productivity in NHS hospitals, February 2016] which concludes that the NHS could save £5 billion, if all trusts were brought in line with its most efficient organisations. But some people have queried whether the underlying data which informed it is correct.”
And she feels the same question should arise when defining exactly what is “good care” when moving to a system which measures outputs and outcomes. “These are all challenges to morale and highlight the need for exceptional leadership to deliver the step changes required to move to new ways of working,” says Crofts. It is little wonder the pace of change seems slow.
With these challenges in mind, DAC Beachcroft is developing a library of information, innovation and good practice based on many years of partnership work with NHS, local authority and independent sector clients who are pioneering integration and new ways of working. This framework model, covering Strategic, Risk, Regulatory and Operational issues, provides practical help in addressing potential barriers to integration.
Under each quadrant, DAC Beachcroft partners have identified a list of issues such as consultation, devolution, health technology and data protection, risk management, insurance and indemnity, and clinical and corporate governance, and property.
This first publication, "The route to integrated healthcare", will cover Strategic issues, focusing on commissioning integration, contracting and corporate structures, and procurement and competition; setting out the significance of each area, the key issues to address, next steps, and practical advice and help from DAC Beachcroft experts including examples of how problems can be solved.
Over the course of the year, DAC Beachcroft will publish a series of advice sheets covering each of the areas. As the firm’s work on new models of care develops, partners will be tracking emerging issues which will help inform these subsequent publications on integration aimed at stakeholders and offer suggestions as to how these obstacles can be overcome.
Part two: commissioning integration
Part three: contracting and corporate structures
Part four: procurement and competition