26.Increased longevity of life was one of the triumphs of the 20th century. The challenge for today is to ensure that those extra years are healthy years. The health service in this country—in common with most of those in the developed world—was designed primarily to treat short-term episodes of ill health and today continues to operate around individual conditions and body parts. Consequently, it is less adapted for frail, elderly people with multiple health conditions.
27.If the system is going to adapt to meet the patient needs and demands of the future, radical service transformation is required. There is wide agreement on the vision for the health system of the future—effective primary and community services, secondary services free from inappropriate use, and more joined-up working between health and social care services—but we were told repeatedly of the barriers that prevent this transformation. If the vision is to become a reality it will require clear direction from the centre but also strong support for local co-operation and place-based commissioning.
28.This chapter sets out the case for service transformation and explores some of the existing efforts. It considers how the different components of the system need to change, examines the progress of integration of the health and social care services and considers what barriers need to be overcome to support the system to adapt to meet demands over the next 10 to 15 years.
29.While the NHS has evolved considerably since its inception in 1948, the drivers of change—from demographic factors and changing disease patterns, to technological and medical advances, income effects and increasing relative health care costs—are intensifying at a relentless pace and fuelling rising public expectations. The system, which was originally designed to treat short-term episodes of ill health is now caring for a patient population with more long-term conditions, more co-morbidities and increasingly complex needs.
Demographic changes will contribute significantly to the levels of demand placed on health and care services over the next 10 to 15 years, and beyond. As the population ages, there will be a likely change to the prevalence of some major diseases and an increase in the number of people with more than one long-term condition.
An ageing population
The Office for National Statistics (ONS) forecasts that the proportion of individuals aged 65 years and over will increase from 18.0% of the population in 2016 to 26.1% in 2066. Growth will be particularly strong among the oldest individuals, with the share of the population aged 85 years and above set to increase from 2.4% to 7.1% over the same period. Figure 1 illustrates the historic and projected changes in the proportion of the population of people aged over 85.
Changes to the burden of disease
Professor Chris Whitty, Chief Scientific Adviser at the Department of Health, detailed the likely change in disease mix expected over the next 20 years. In his view it was reasonable to expect the continuation of some of the trends seen in the last 30 years. For example, improvements in primary and secondary prevention mean that the incidence of cardiovascular disease (heart disease, acute stroke, some vascular dementia) and some major cancers (for example lung, cervical, gastric) will reduce.
Other diseases are likely to reduce in incidence but increase in prevalence due to better survival—stroke is an example. This will have significant implications for the skill mix needed in the professions 20 years on. Meanwhile some diseases will increase in prevalence due to successes in other areas (for example some infectious diseases and some cancers). Professor Whitty suggested that the most prominent of these will most likely be dementia.
Sources: ONS figures cited in Institute for Fiscal studies, IFS Green Budget, UK health and social care spending (7 February 2017): [accessed 28 March 2017] and written evidence from Professor Chris Whitty ()
30.There was widespread agreement throughout our evidence that the NHS’s current delivery model was outdated and struggling to keep pace with the changes outlined in Box 1. Michael Macdonnell, Director of Strategy at NHS England, told us: “If we had to recreate the system, none of us would recreate what we currently have.”
31.The issue of whether the health system and the models of care within it reflect the needs of the patients it cares for is of central importance. Underpinning much of the evidence we received was a clear agreement that without the necessary service transformation, tantamount to a “fundamental reinvention of the delivery model”, greater sustainability could not be achieved.
32.We asked many of our witnesses the same question—what does the healthcare system of 2030 look like and what do we need to get there? As a result, we were able to obtain a very clear articulation of what key components a sustainable system would need to include. A number of consistent themes emerged:
(1)The urgent need to shift more care away from the acute sector into primary and community settings;
(2)Widespread support for closer integration of health and social care services (as far as organisation and budgets are concerned); and
(3)The need to resolve the current fragmentation of the health system, which is making the provision of co-ordinated care impossible and frustrating efforts to move toward place-based systems of care.
33.A conclusive shift away from hospital-based care towards delivering care through primary and community-based services was perhaps the most prominent of the calls for service transformation. The Department of Health confirmed that: “Our focus and interest are in how you shift activity and resources from acute to community settings.” Public Health England echoed this, stating that: “What we are looking for to happen over the next few years is new, more integrated services outside of the acute setting done at scale in primary and community settings.”
34.The evidence was also overwhelmingly in favour of the integration of health and social care services and budgets, with more of these services, including mental health services, provided on a community basis. The Royal College of Nursing was one of many witnesses that suggested that integration was central to the long-term sustainability of the health and care system, and critical to facilitating positive system change, stating that:
“The reality is that the failure to fund either effectively, or address people’s needs through design and delivery of integrated services, is negatively impacting both funding and outcomes. We must consider these aspects of care and support as fundamentally connected and interdependent, rather than seeing them in isolation from one another.”
35.The current strategic vision for the NHS is set out in the Five Year Forward View which was published in October 2014. It was published under the leadership of its current Chief Executive, Simon Stevens of NHS England, and outlines a vision for the future of the NHS based around new models of care. It focuses on a number of themes such as the importance of public health and ill-health prevention, empowering patients and communities, strengthening primary care and making further efficiencies within the health service.
36.A core aim of the Five Year Forward View was to undertake “radical action to transform the way NHS care is provided.” To achieve this, it set out how NHS England would “support and stimulate the creation of a number of major new care models” to help meet the changing needs of patients. Some of the new models include:
37.These new models of care are being delivered through a series of ‘vanguard’ sites across the country. Michael Macdonnell told us that: “The new care models programme is based on a vision of where we want to get to.”
38.The general direction of travel set out in the Five Year Forward View was strongly supported as a basis for making the NHS more sustainable. Organisations including the Academy of Medical Royal Colleges, the Faculty of Public Health and the Shelford Group all indicated in their submissions that they agreed with the vision for service transformation outlined in the Forward View.
39.We were told that there were plans to extend the Five Year Forward View. Simon Stevens, told us that NHS England would publish a set of proposals, which would be “a manifesto if you like, for what going into the next Parliament it should look like over the medium term.” Mr Stevens indicated that it was likely that this would be published in the near future.
40.Despite the assurance that the Forward View would be revisited we were concerned that there appeared to be a significant lack of long-term thinking around how the momentum on service transformation will be maintained. As the Health Foundation emphasised:
“Delivering the vision and funding set out in the Forward View is a necessary step towards a sustainable health care system but not a sufficient one. Beyond the Forward View, action will be needed to secure a high quality, sustainable health and care system for the 2020s.”
41.NHS Providers raised similar concerns and told us that:
“… there is no clarity about how the government’s commitment to integrate care by 2020 will be delivered and a real lack of vision and strategy for integration or service reconfiguration beyond this period to 2035.”
42.It appears that in terms of service transformation (and in other areas we outline later in this report) the view of policymakers is set no further than 2020. Chris Wormald, Permanent Secretary at the Department of Health, confirmed that:
“Of course like any Government department our primary focus is on delivering the manifesto right now. Our focus is unashamedly on the next five years delivering the five year forward view … We are not in the business of publishing long term plans, future visions of the health service beyond the current Parliament but we are in the process of a constant horizon scanning.”
43.Most people agree that key aspects of the service delivery model for the NHS need to change. There is also broad agreement on how this should happen. The general direction of NHS England’s Five Year Forward View commands widespread support and, if fully realised, will place the NHS on a far more sustainable footing, especially if greater public support can be achieved.
44.The Five Year Forward View appeared to be the only example of strategic planning for the future of the health service. This is clearly short-sighted. Without a longer-term strategy for service transformation, which goes beyond 2020, any short-term progress achieved through the Five Year Forward View will be put at risk.
45.The Department of Health and NHS England, in partnership with the Department of Communities and Local Government, the Local Government Association and the Association of Directors of Adult Social Services, should agree a medium-term plan that sets out the action required to deliver sustained service transformation at a local level. This plan should cover the period up to at least 2025, be supported by dedicated funds and be implemented following a full public consultation.
46.Sustainability and Transformation Plans (STPs) were announced in December 2015. As a result, NHS organisations and local authorities in different parts of England have been required to produce a multi-year ‘place-based plan’ showing how local services will evolve and become sustainable over the next five years—ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency.
47.Final plans from the 44 STP areas were submitted in October 2016. The plans are likely to be assessed and approved in phases, depending on their quality. From April 2017, STPs will become the single application and approval process for accessing NHS transformation funding, with the best plans set to receive funds more quickly. STPs were described by the Department of Health as a “genuine attempt to go for place-based commissioning … trying to involve the local NHS plus social care plus public health, to bring them all together to plan on a five-year, more strategic basis.”
48.We noted that the Department of Health and NHS England were clear that they saw STPs as a key way in which to tackle some of the system’s most significant pressures and were central to realising the vision set out in the Five Year Forward View. In November 2016, Simon Stevens said:
“The Five Year Forward View is a vitally important plan. It’s about the move to accountable care organisations, about the move to prevention and not cure. And it has the support of the NHS, and it is vital that we stick with that plan and implement it. And there will be lots of challenges and lots of bumps in the road but the sustainability and transformation plans are the way that we implement the Five Year Forward View and it is vital we stick with them.”
49.Amongst our witnesses, though there was broad support for STPs and their role in securing the sustainability of the NHS, some witnesses expressed concerns about the STP process.
50.Currently, STPs have no statutory basis. However, several individual statutory organisations, such as clinical commissioning groups, will be involved in each Plan. There is, therefore, considerable ambiguity around the governance of STPs which threatens to undermine the ability of STP areas to drive changes to services. Sir Robert Naylor, former Chief Executive of the University College London Hospitals NHS Foundation Trust, said:
“There are, however, a number of challenges that STPs will need to overcome if they are to deliver the improvements that the NHS needs. The first is about governance and engagement. STPs have been set up relatively quickly, with multiple conflicts of interest and without a statutory basis. That will not give them the authority they will need to drive through difficult decisions about service changes and distribution of financial risks. They will be unable to deliver significant estate changes, including investment in primary care, because the majority of assets are ‘owned’ by the acute foundation trusts who are not responsible for the whole patient pathway.”
51.The scale of the financial challenge facing both the health and care systems makes it extremely difficult to achieve the service transformation that so many agree is needed. Concerns were raised that, although STPs were regarded as an important mechanism to help transform the way care is delivered, without sufficient investment, they would not be able to achieve sustainable change.
52.When asked whether the transformation fund (the funding that has been made available to support the implementation of the Five Year Forward View through STPs) would be sufficient, Richard Murray, Director of Policy at The King’s Fund, told us: “At the moment, no. Much of the transformation funding that is available will end up being directed at deficits in the acute sector.”
53.In this year’s Budget, published on 8 March, the Chancellor of the Exchequer announced £325 million of new capital funding for STPs. The investment will be allocated to the ‘strongest’ STPs and will be spread over three years, with further funding to be considered in the autumn. While this additional funding is welcome, we agree with those who have described this as falling short of what is required, given the significant amount of new capital investment that the plans are likely to need over the next five years, which has been estimated at around £10 billion. There is a real risk that the funds which will be made available to STPs will be swallowed up by efforts to sustain local services instead of transforming them.
54.In its recent report on the progress of STPs, Sustainability and transformation plans, from ambitious proposals to credible plans (February 2017), The King’s Fund concluded that:
“The context in which STPs have emerged is much more challenging than when the Forward View was published, with the NHS now facing huge financial and operational pressures. The changes outlined in STPs could help address these pressures, but there is a risk that work to sustain services will crowd out efforts to transform care.”
55.For place-based commissioning to work, NHS organisations will need to work closely with local partners including local authorities, the voluntary sector and the public. The Local Government Association told us that “It is vital that time is invested in engaging councillors and MPs in the development stage of Sustainability and Transformation Plans, to ensure that communities’ wishes are understood, and to minimise the likelihood of challenge or delay to proposals.”
56.We were therefore concerned to hear reports that in some STPs areas there has been a lack of engagement with councillors and communities in the planning process. The King’s Fund research on the progress of STPs highlighted that engagement with local authorities had been patchy, stating that “The strength and depth of local authority involvement in the plans has varied between STP footprints, ranging from strong involvement in decision-making and planning to very weak involvement in all aspects of the process.”
57.We also received evidence demonstrating a lack of public involvement in these developments. The Chief Executive of the Patients Association, Katherine Murphy, told us that, regarding STPs:
“… the public were not consulted on what services should be provided in their local communities. The public are very willing to become involved. They want to be involved; they want to be consulted and talked to and given the correct information. They would like to be involved in an open, transparent and meaningful way. They understand the reasons why services have to be cut within the NHS. What they fail to understand is why such major plans are being drawn up without any consultation with patients and the public.”
58.We applaud the move towards more place-based commissioning which delivers integrated health and social care services. At this early stage it would be premature to make a judgement about the current effectiveness of Sustainability and Transformation Plans but we doubt the ability of a non-statutory governance structure to secure sustainable change for the medium and longer term. NHS England, with the support of the Department of Health, should ensure that all 44 Sustainability and Transformation Plan areas have robust governance arrangements in place which include all stakeholders, including NHS organisations, local government, the voluntary sector and the public.
59.We are concerned by the reported lack of engagement with either local authorities or the wider public in the preparation of Sustainability and Transformation Plans. This will deter buy-in at a local level and jeopardise ongoing political support.
60.In addition to STPs, we heard evidence about initiatives to devolve more responsibility for health and social care to local areas as another way of encouraging bespoke local solutions to service transformation. We heard evidence from individuals involved in perhaps the most high profile of these devolution projects—the devolution of health and social care spending to Greater Manchester—which is outlined in more detail in Box 2.
The Greater Manchester Agreement, signed in November 2014, set out new powers over transport, housing, planning and policing for the Greater Manchester Combined Authority.
In April 2016 the region became the first in the country to take control of its combined health and social care budgets. Following the signing of a memorandum of understanding Greater Manchester now controls the full devolution of a budget of around £6 billion in 2016/17.
A new strategic board, the Greater Manchester Health and Social Care Partnership, was created to take charge of the £6 billion health and social care budget. The Partnership comprises 37 NHS organisations and councils, including:
61.Sir Howard Bernstein, Chief Executive of Manchester City Council, told us how devolution of health was working there:
“We are seeking to join up community services with social care, mental health and primary care in order to provide the integrated offer that is necessary, not only to support a transformation in our population’s health through prevention and early intervention but in effect, to reduce the demand for services in our hospitals. That is how we see this strategy.”
62.There were, however, doubts expressed as to how well the Greater Manchester example could be rolled out in other areas. Baroness Cavendish of Little Venice told us:
“Manchester is I’m afraid unique. I don’t think there is any other part of this country that has the same constellation of talent in terms of the NHS and local authorities. I don’t believe there is anywhere else that has the same political impetus because it is essentially a political construct so what we are doing at the moment is we are basing our aspiration for STPs upon a hope that politicians in local areas will be able to come together in a way they are doing in Manchester. I think it would be very foolish to expect anyone else to adopt the Manchester model.”
63.The evidence was mixed on the contribution of devolution to the long-term sustainability of health and social care. There are undoubtedly lessons to be learnt from devolution, but the evidence was not clear on how well the model in Greater Manchester could be replicated nationally especially as many, if not most, of the Sustainability and Transformation Plans (STPs) are for much smaller populations than that of Greater Manchester.
64.Current efforts on service transformation have largely prioritised the changes which need to be made to ensure existing services in the community are used more effectively to moderate demand for hospital care, and changes to improve the integration of health and social care services to provide more comprehensive and joined-up care to patients.
65.The necessary service transformation is happening but belatedly and, we fear, at an inadequate scale and pace. Efforts to transform the way care is delivered are being seriously hindered by the fragmented nature of the current governance system and a considerable degree of uncertainty over who is responsible for driving service transformation as distinct from current service delivery.
66.The Five Year Forward View states that primary care will remain “the foundation of NHS care.” However, we received a considerable amount of evidence on the current pressures within primary care, and the resulting impact of those pressures on other parts of the system.
67.The Royal College of General Practitioners highlighted the most pressing issues facing general practice:
68.These challenges are frustrating efforts to deliver more care in primary and community settings in order to reduce pressures in the acute sector. There were concerns that the current longstanding model of primary care is not fit for the purpose of delivering the desired shift away from the acute sector. We heard that there has been historic and damaging underfunding of the primary care sector, as highlighted in NHS England’s General Practice Forward View, which stated that over the past ten years governments have “cut the share of funding for primary care and [grown] the number of hospital specialists three times faster than GPs.” This has had an impact on GP workload and added to “growing patient concerns about convenient access.” A clear message from the evidence was that the model of primary care required urgent reform to deliver the required service transformation. The General Practice Forward View acknowledged this, highlighting a report by the Primary Care Foundation and the NHS Alliance, which stated that:
“The strength of British general practice is its personal response to a dedicated patient list; its weakness is its failure to develop consistent systems that free up time and resources to devote to improving care for patients. The current shift towards groups of practices working together offers a major opportunity to tackle the frustrations that so many people feel in accessing care in general practice.”
69.We found broad support for the new Multispecialty Community Provider care model and, in particular, the move towards GP practices working at scale to deliver extended services through federations. Dame Julie Moore, Chief Executive of University Hospitals Birmingham NHS Foundation Trust, told us:
“… the model that we expect them [GPs] to operate sometimes is no longer fit for this day and age. The demands placed on primary care are huge and demand is outstripping that. We need to look at new models of primary care and how we work more closely together in 24-hour services and actually relieve some of the pressure … we can only do that by working in bigger centres, working together and providing round-the-clock access that patients now need. I think we need to look again at the whole model of provision.”
70.Similarly, Chris Hopson, Chief Executive of NHS Providers, suggested that:
“… there is a widespread agreement that the 1948-bequeathed structure of a bunch of single-handed practices led by individual GPs is unable to provide the kind and scale of primary care that we now need, and there is a rapidly growing development where people are coming together in GP federations which make it easier and more effective to then link up all these different parts of health and social care.”
71.The suitability of the current independent contractor status of most GPs was questioned. Dr Clare Gerada, General Practitioner and former Chair of the Royal College of General Practitioners, suggested this arrangement “was not fit for purpose.” Sir Sam Everington, Chair of the NHS Tower Hamlets clinical commissioning group, suggested that this could be resolved by considering local contracts: “If you are to shift that care out of hospital with … different solutions around the country, you have to come up with locally sensitive contracts to make that happen.”
72.The Chair of the Royal College of General Practitioners, Dr Helen Stokes-Lampard, agreed: “We all have to be realistic about what the future holds, and, whilst personally I love the partnership-led model of general practice, I know it is not likely to be fit for the long-term future and that we have to have local solutions for local problems.”
73.Lord Darzi of Denham also commented on the contractual arrangements within general practice:
“What we got wrong in the original polyclinic … is that we described what this looked like, a federation, but we never really looked at the business model. In the NHS we are not good at business model innovation. We look at technological process innovation, but there are many business models that you can use to ignite the interest in primary care, whether they are partnership or employment models. We have to understand that the primary care community and leadership are also very divided; we can stratify them into those who would like employment contracts and those who would like to build partnerships.”
74.Despite a clear move from GPs in some areas towards operating in federations, there appeared to be little support or direction from the centre to drive this agenda. Beyond the Five Year Forward View, clear and determined leadership from the centre is required to identify a process for adapting the primary care model and its contractual basis to ensure it has the flexibility to meet the needs of patients in the future. It was not obvious to us who is going to provide this leadership.
75.In addition, we heard that there is a clear case for reforming the primary care workforce so that a range of other healthcare professionals such as nurses, community pharmacists and mental health counsellors can work in a team alongside GPs to support their work. Professor Maureen Baker, Former Chair of the Royal College of General Practitioners, emphasised the need for “high-level nursing skills in the community” and highlighted the suggestion of “a model used in the US where you have colleagues who support the doctor in doing a lot of admin, form filling and basic clinical tasks.” Professor Baker stated that: “We are saying we need this range of skills, we need GPs—we need as many GPs as we can get—and we need other colleagues to work so that they have the right workforce with the skills that 21st century patients need in the community.”
76.The traditional small business model of general practice is no longer fit for purpose and is inhibiting change. NHS England, with the help of the Department of Health and the profession, should conduct a review to examine alternative models and their contractual implications. The review should assess the merits of engaging more GPs through direct employment which would reflect arrangements elsewhere in the NHS.
77.Over-reliance on the acute sector is a serious threat to the financial sustainability of health and care services. NHS Clinical Commissioners told us: “We are concerned that without a significant reduction in expensive hospital activity and a transformation in health and care delivery that makes better use of available resources the NHS will be unable to adequately respond to changing population needs.”
78.Those secondary care hospitals which serve towns and small conurbations provide a range of services for their local populations and face different sets of problems from specialised hospitals or units. In providing acute surgical, orthopaedic, medical and obstetric care for seriously ill patients, many of whom enter through A&E Departments, their facilities are vulnerable to being overwhelmed by patients with long-term care needs that are not being met by community services. Such hospitals house expensive diagnostic and therapeutic resources, such as imaging and operating theatres, and these may be used inefficiently when patients remain in hospital unnecessarily, reducing the availability of beds for other patients in need. There is also ongoing concern around levels of productivity within this sector, as highlighted by the Carter Review.
79.The continued pressures on the acute hospital inpatient sector require a reshaping of secondary care to meet the needs of an increasingly ageing population. Many of these people live with multiple chronic conditions and are increasingly finding themselves being cared for in high-cost and inappropriate hospital settings.
80.We acknowledge that over-reliance on the acute hospital inpatient sector is a serious threat to the financial sustainability of health and care services. This sector should be radically reshaped in terms of service provision but changes to the number, size and distribution of secondary care services should always reflect the needs of the local population. Any changes should take place following a broad consultation.
81.A number of witnesses highlighted examples in the NHS where some specialised services, such as for cancer or cardiac surgery, had been concentrated into fewer hospitals to improve the quality of care, efficiency and effectiveness. It was suggested that further consolidation of specialised services should be a key consideration for future service transformation.
82.Specialised and highly specialised hospitals tend to be found in large city conurbations. Although there is a danger of duplication from services located within relatively short distances of each other, there is little doubt that focusing such expensive specialised services in specific areas ensures high levels of expertise and care. The success of centralising services that dealt with stroke, trauma and heart attacks was highlighted. Sir Cyril Chantler, an eminent paediatrician, highlighted the provision of centralised, specialised services in London, stating that: “London has gone from being one of the more dangerous capital cities in which to have a stroke to perhaps the safest.”
83.Professor Andrew Street, from the Centre of Health Economics at the University of York, expressed disappointment that there had been a missed opportunity for further service transformation over the last 10 to 15 years, but cited the consolidation of specialised services as a success:
“You mentioned in the previous session the development of treatment centres as a different model of delivering care; small, self-contained, specialising in particular treatments, and although they were expensive to set up in the first place, they now tend to deliver high-quality care at a lower cost, with lower lengths of stay and better outcomes for patients, than they would if they had gone through the normal run of the hospital sector.”
84.The Specialised Healthcare Alliance, however, warned that there was still work to be done and that further progress on consolidation of specialised services was being impeded by a number of issues:
“… attempts to reconfigure specialised care provision have typically met competing provider interests, political interventions and regulatory barriers preventing service change. Challenges such as these have historically stymied progress towards specialised services consolidation.”
85.The drive to consolidate specialised services is a necessary part of overall service transformation. However, as with primary care, we were left with no clear picture of how specialised service consolidation will be delivered in the medium and the longer term.
86.For the most part, in England, health and social care services are separate. NHS England is responsible for healthcare and local authorities are responsible for means-tested social care. With the population ageing and the prevalence of long-term conditions and co-morbidities increasing, more and more patients require both health and social care. The separation between the two is becoming increasingly problematic.
87.Improved integration between health and social care services is often put forward as a way of reducing costs, easing the pressure on commonly-used services and delivering a better overall experience for patients. NHS England’s approach to integration policy uses the following definition of integrated care:
“… person-centred, coordinated, and tailored to the needs and preferences of the individual, their carer and family. It means moving away from episodic care to a more holistic approach to health, care and support needs, that puts the needs and experience of people at the centre of how services are organised and delivered.”
88.In England, recent policy efforts have been focused on encouraging local areas to co-ordinate resources and enabling financial integration between health and social care services. In April 2015 the Government launched the Better Care Fund, a joint initiative between the Department of Health, the Department for Communities and Local Government, NHS England and the Local Government Association. The Fund requires local health bodies and local authorities in each area to pool funding, a minimum of £3.8 billion in 2015/16 and £3.9 billion in 2016/17. Local bodies are required to produce joint plans for integrating services and to submit these plans to NHS England. Many areas chose to go beyond the minimum pooled funding requirements, resulting in a total of £5.3 billion being pooled in 2015/16 and £5.8 billion in 2016/17.
89.A recent report by the National Audit Office (NAO) cast doubt on the effectiveness of the Government’s plan for integrated health and social care services. While it acknowledged that the Fund had been successful in incentivising local areas to work together, with more than 90% of local areas agreeing or strongly agreeing that the delivery of their plan had improved joint working, the NAO report was clear that the Government’s policy on integration had not delivered on its ambitions of releasing savings, reducing emergency admissions and delayed discharges and, crucially, delivering better outcomes for patients. The report concluded:
“… progress with integration of health and social care has, to date, been slower and less successful than envisaged and has not delivered all of the expected benefits for patients, the NHS or local authorities. As a result, the government’s plan for integrated health and social care services across England by 2020 is at significant risk.”
90.Although the NAO’s report was published after we had finished taking evidence, many of the witnesses conveyed the same sense that, despite a long history of initiatives aimed at joining up health and social care services, progress had been incredibly slow. Some witnesses presented the difficulty of integrating budgets as almost insurmountable; system-wide integrated services were still very far from being a reality. Integration policy has been discussed for decades but it was clear from the evidence that there was a degree of frustration at the lack of progress on the integration of either funding or service delivery.
91.Many of the sources of evidence were in agreement that better integration of health and social care services would support improved patient experience. Chris Hopson told us that: “What it [integration] does relatively quickly, it seems, is produce a better quality of patient and service-user experience.” What was less clear was whether integration offered the potential for substantial cost savings. Dr Edward Scully, Deputy Director, Integrated Care at the Department of Health, told us:
“My own take is that the potential for savings through integration of health and social care is not what people have set out; it is more limited. It is not a utopia or a panacea for releasing savings.”
92.Despite the uncertainty over the direct financial savings that might be released through improved integration, it is nonetheless viewed as a vital element of service transformation. Overcoming the barriers to improved integration will be central to securing the long-term sustainability of both health and care services. Dr Sarah Wollaston MP, Chair of the House of Commons Health Select Committee, told us:
“I think that if we continue to have a very fragmented model we will be missing many opportunities to commission much more logically for health and social care … By having separated, fragmented systems for health and social care, we are wasting energy and money and are not meeting people’s needs, so I think that should be a clear priority for the future.”
93.The complex and fragmented organisational arrangements of health and care services are making the integration of services much more difficult. With budgets and staff in different organisations, coherent governance of, and accountability for, service transformation is extremely challenging. Sir Cyril Chantler described an “overall strategic uncertainty” which was apparent to us in the lack of clarity over who was primarily responsible for securing service integration as part of wider service transformation. For too long integration has seemed everybody’s responsibility and nobody’s responsibility.
94.Although recent efforts to promote joined-up health and social care services have delivered mixed results, integrated health and social care with greater emphasis on primary and community services still presents the best model for delivering patient-centred, seamless care. Although there is disagreement on the financial gains to be derived from this integration, the benefits to patients are a clear justification for continuing to pursue this agenda.
95.The Health and Social Care Act 2012 introduced wide-ranging reforms to the NHS which included a radical restructuring of the health system. The Act established a new executive non-departmental public body called NHS England, to oversee the budget, planning and delivery of the commissioning side of the NHS; clinically led statutory NHS bodies (clinical commissioning groups) responsible for planning and commissioning of health care services locally; established Public Health England and Healthwatch England; and introduced provider regulation on competition issues, overseen by Monitor, which was later merged with other organisations under an umbrella organisation as NHS Improvement.
96.Many witnesses suggested that the restructuring of the system by the Health and Social Care Act 2012 had resulted in an extensive fragmentation of services. This, witnesses argued, was continuing to act as a serious impediment to devolution, integration and new ways of working. The Centre for Health and the Public Interest suggested that the Act’s provisions were frustrating the current efforts on service transformation, stating that:
“The Five Year Forward View’s central aim is better integration of the NHS. But the provisions of the Health and Social Care Act of 2012 are aimed at promoting competition, the opposite of integration. In trying to achieve the aims of the [Five Year Forward View] commissioners and providers have to ‘work around’ the Act, working against its aims but in conformity with its legal provisions. Planning is thus being undertaken by ad hoc groups of local commissioners and providers working outside any legal framework and doing only what the Act does not explicitly forbid. Informal and unaccountable government of this kind tends to produce bad policies as well as being prone to conflicts of interest and corruption.”
97.Similarly the PHG Foundation suggested that the Health and Social Care Act 2012 had made service transformation and an integrated approach to delivering care harder to achieve, as:
“… the financial and organisational independence of hospital trusts (reinforced by the Health and Social Care Act 2012) results in misaligned incentives to compete, not co-operate and to a drive to develop ‘distinctive’ services rather than learn from and adopt best practice developed elsewhere.”
98.The King’s Fund recently highlighted, in its report Delivering sustainability and transformation plans, that amendments were needed to the aspects of the Act that were not aligned with the aims of the Five Year Forward View and STPs. It suggested that:
“The sections of the Act relating to market regulation would particularly benefit from review, both in relation to the role of the CMA [Competition and Markets Authority] and requirements on commissioners to use competitive processes in procuring new care models. There is also a need to recognise more formally the role that STPs are expected to play alongside the boards of NHS organisations and local authorities.”
100.NHS England and the Department of Health should launch a public consultation on what legislative modifications could be made to the Health and Social Care Act 2012 which would remove the obstacles to new ways of working, accelerate the desired service transformation and secure better governance and accountability for achieving system-wide integrated services.
101.Service transformation is dependent on long-term planning, broad consultation, appropriate systems of governance and local accountability. The model of primary care will need to change, secondary care will need to be reshaped and specialised services consolidated further. Importantly, a renewed drive to realise integrated health and social care is desperately needed. However, the statutory framework is frustrating this agenda and in order for real progress to be made the national system is in need of reform to reduce fragmentation and the regulatory burden.
102.With policy now increasingly focused on integrated, place-based care we see no case for the continued existence of two separate national bodies and recommend that NHS England and NHS Improvement should be merged to create a new body with streamlined and simplified regulatory functions. This merged body should include strong representation from local government.
16 (Michael Macdonnell)
17 (Tom Kibasi)
18 (Graham Duncan)
19 (Adrian Masters)
20 Written evidence from the Royal College of Nursing ()
21 NHS England, The Five Year Forward View (October 2014), p 14: [accessed 28 March 2017]
23 NHS England, ‘The Five Year Forward View—the executive summary’: [accessed 28 March 2017]
24 (Michael Macdonnell)
25 Written evidence from the Academy of Medical Royal Colleges ( the Faculty of Public Health ) and the Shelford Group ()
26 (Simon Stevens)
27 Written evidence from the Health Foundation ()
28 Written evidence from NHS Providers ()
29 (Chris Wormald)
30 The King’s Fund, ‘Sustainability and transformation plans (STPs) explained’: [accessed 28 March 2017]
31 (Dr Edward Scully)
32 GP Online, ‘STPs ‘vital’ for future of NHS, Jeremy Hunt MP has told health leaders’: [accessed 28 March 2017]
33 Written evidence from Sir Robert Naylor ()
34 (Richard Murray)
35 HM Treasury, Spring Budget 2017 (March 2017), p 48: [accessed 28 March 2017]
36 The Health Service Journal, ‘Leading STPs to get ‘very modest’ £325 million capital funding’ (8 March 2017): [accessed 28 March 2017]
37 The King’s Fund, Delivering sustainability and transformation plans From ambitious proposals to credible plans (21 February 2017): [accessed 28 March 2017]
38 Written evidence from the Local Government Association ()
39 The King’s Fund, Sustainability and transformation plans in the NHS, How are they being developed in practice? (November 2016), p 34: [accessed 28 March 2017]
40 (Katherine Murphy)
41 (Sir Howard Bernstein)
42 (Michael Macdonnell), (Chris Wormald), and (Baroness Cavendish of Little Venice), (Simon Stevens) and (Mark Britnell)
43 (Baroness Cavendish of Little Venice)
44 The King’s Fund, Delivering sustainability and transformation plans, From ambitious proposals to credible plans (February 2017): [accessed 28 March 2017]
45 NHS England, ‘Five Year Forward View’: [accessed 28 March 2017]
46 Written evidence from the Royal College of General Practitioners ()
47 NHS England, General Practice Forward View (April 2017): [accessed 28 March 2017]
48 Primary Care Foundation and NHS Alliance, Making Time in General Practice (October 2015): [accessed 28 March 2017]
49 (Dame Julie Moore)
50 (Chris Hopson)
51 (Dr Clare Gerada)
52 (Sir Sam Everington)
53 (Dr Helen Stokes-Lampard)
54 (Lord Darzi of Denham)
55 (Professor Maureen Baker)
56 Written evidence from NHS Clinical Commissioners ()
57 Lord Carter of Coles, Operational productivity and performance in England NHS acute hospitals: Unwarranted variations, An independent report for the Department of Health by Lord Carter of Coles (February 2018): [accessed 28 March 2017]
58 Written evidence from Sir Cyril Chantler ()
59 (Professor Andrew Street)
61 National Collaboration for Integrated Care and Support, Integrated Care and Support: Our Shared Commitment (May 2013), p 1: [accessed 28 March 2017]
62 NHS England, ‘Integrated care and support’: [accessed 28 March 2017]
63 The National Audit Office, (Session 2016–17, HC 1011)
64 National Audit Office, Press Release: ‘Health and social care integration’, 8 February 2017: [accessed 28 March 2017]
65 (Chris Hopson)
66 (Dr Edward Scully)
67 (Dr Sarah Wollaston MP)
68 Written evidence from Sir Cyril Chantler ()
69 Written evidence from the Centre for Health and the Public Interest ()
70 Written evidence from the PHG Foundation ()
71 The King’s Fund, Delivering sustainability and transformation plans From ambitious proposals to credible plans (21 February 2017): [accessed 28 March 2017]