Integrating care: Next steps to building strong and effective integrated care systems across England Our response to NHS England’s consultation

3 February 2021

Key points

  • The benefits of integration risk being overstated: overall, the emphasis on closer collaboration between the NHS, local government, and other agencies makes sense. Evidence suggests that integrated care may improve patient satisfaction, access to services, and perceived quality of care, but evidence of impact on resource use and health outcomes is limited—and the magnitude of potential positive effects may be modest and take time to be realised. Formal duties to collaborate or merging NHS functions does not necessarily produce collaboration in practice. 

  • Risk of major disruption: the redevelopment of the regional tier through integrated care systems (ICSs) fits with the historical development of the NHS and could improve the murky accountabilities in today’s health system. But creating organisations is easier on paper than in practice: experience shows that merging and creating new agencies can cause major disruption. Primary care networks are expected to play a central role in ‘places’ and integrated care systems. But these networks are nascent and small-scale, and redefining their functions risks derailing early progress.  

  • Past reorganisations have delivered little benefit: it is hard to see how the proposals to abolish clinical commissioning groups (CCGs) and create ICSs would avoid another major reorganization of the health care system. Evidence suggests that previous structural reorganisations in the NHS have delivered little measurable benefit. Other policies to support NHS improvement, such as boosting investment, are likely to have had a greater impact on performance. Reorganisations can also have negative and unintended effects, such as destabilising services and relationships. 

  • How will integrated care systems work?: Limited detail is provided on how ICSs will work and interact with other parts of the health system, including new NHS provider collaboratives. It is also unclear how the ‘place’ level of the new NHS would be organised and the roles of different agencies. The role of local authorities is poorly defined. This is a major weakness given that local authorities play a central role in addressing social, economic, and environmental determinants of health. 

  • Broader policy approaches to support improvement: the exact future and approach for commissioning is unclear from the proposals. Past experience suggests that NHS commissioning in and of itself has failed to have a significant impact on care or outcomes. Greater attention needs to be given to developing the blend of policy levers to support improvement in complex systems—including by strengthening the NHS’s capabilities to identify, implement, evaluate, and spread improvements in different contexts. Changes to simplify procurement rules and make joint purchasing decisions easier should help reduce fragmentation and complexity. 

  • The NHS needs an updated strategy when it emerges from the pandemic: the scale of the challenges facing the NHS are staggering. The public policy challenges facing government are even bigger. NHS leaders need to articulate how changes to NHS structures fit within a new guiding strategy for the health and care system after COVID-19. The ambition to close the gap between the ‘rules in form’ and the ‘rules in use’ in today’s NHS makes sense—and the need for legal changes to reduce fragmentation and complexity has long been recognized. But any changes to legislation should be targeted and backed by clear evidence or logic. This may mean initially pursuing limited policy fixes to amend competition rules and strengthen the power of ICSs that can evolve over time. A major structural reorganisation would not be the answer to the problems facing the NHS and its patients after COVID-19. 

In November 2020, NHS England published proposals for changes to NHS structures and legislation in England, and asked for feedback. 

To respond to these plans, we produced a short paper assessing the new proposals and identifying issues to be addressed as the plans develop. In early January, we summarised the key points and considerations from the paper in our response to NHS England’s consultation. 

The paper was published by the BMJ in February and a copy of the paper is below.

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