Destination integration: unanswered questions over the latest NHS reforms

After months of consultation with NHS England, Health Secretary Matt Hancock presented the Government’s White Paper on the future of health and social care to the House of Commons on 11^th February: “At its heart, this white paper enables greater integration, reduces bureaucracy and supports the way that the NHS and social care work when they work at their best: together.”

Hoped to be a silver bullet for purses and patient outcomes alike, “integration” is the buzz word policymakers are scrambling to jam into the title of every publication to come out of a think tank or Gov.UK publication on health for the last five years. But what can we expect from papers that promise “Integration and Innovation: Working to Improve Health and Social Care for All”, or “Integrating care: next steps to building strong and effective integrated care systems across England”?

Discussions on integration have been going on for many years, but certainly the recent interest in integration cannot be extricated from its uncomfortable context in the ruins of the Health and Social Care Act 2012. This hangover from the coalition years has been causing headaches in Westminster and the health service for some time; David Cameron even conceded in his memoirs that the reforms “took up a lot of energy and missed the biggest targets we should have been aiming for”. Its critics go further. Delivered at the height of austerity, the reforms centralised the health service and created an internal market which, many argue, resulted in scattered responsibility, competition between services and a huge burden of paperwork and often arbitrary targets on staff.

Out of these dying embers – dealt their final blows by the COVID-19 pandemic – rises the hopeful Integrated Care System (ICS). Its purpose? To provide care that links up the many organisations and systems existing to help us live healthily and happily, dodging bureaucratic processes and missed patient engagement opportunities while it’s at it. By establishing the structures of working in partnership, focusing on broader metrics of success, and acknowledging the wider determinants of health in the strategic commissioning process, our healthcare leaders are planning for an overhaul, with integration at its beating heart.

There are a lot of unanswered questions about ICSs and the NHS White Paper, including:

• Exactly how ICSs will take on responsibility for specialised commissioning, especially given many charities have fought hard for often ignored conditions to have care mandated and directed at a national level.
• The scope and extent of the Secretary of State’s new powers over the health service.
• The extent to which ICSs will be able to deliver their objectives, given the cuts to local authority budgets which pay for public health and social care.
• How ICSs will involve and consult the voluntary sector, given the frequent mention this in the NHS White Paper.

Following the formal establishment of ICSs in all parts of England at the start of this month, we’ll be keeping a close eye out for answers to these questions, as well as how the theory of integration and collaboration relates to actual improvement for patients accessing care.