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The journey to integration: Learning from seven leading localities

Across the country most areas are now pursuing a vision for integration to deliver better sustainable health and care to respond to the pressure of an ageing population, gaps in care today, and the tight fiscal environment. Starting locally, some areas have led the way, demonstrating the potential to do things differently: investing more in prevention and community based care, reducing unnecessary hospital activity, and facilitating both of these with the key enablers of information management, new payment models, system-wide governance arrangements and workforce reform. These developments have in several areas shown what is possible in the UK and also tracked the emergence of similar models elsewhere across the globe. National policy has come to follow these in the form of devolution, the Care Act, Better Care Fund, Five Year Forward View and the new care models, among others.

And within that there is a clear push among commissioners to commission on the basis of a place, overcoming artificial barriers established within the NHS and between health and care. After an extended time focusing on commissioning, there is now renewed emphasis on how provider models need to be different, and the requirements from commissioners and the system as a whole to facilitate this. The main thrust has been on moving towards embracing population health and the integration of health and care. That is easier said than done.

This report has attempted to understand the successes and challenges of some of the leading areas in pursuing this agenda. All of this comes against a backdrop of a settlement from the Spending Review which, although including allocations for social care and the NHS, also brings significant additional responsibilities and pressures. The implication is that it is more critical than ever for commissioners to shift their focus to a greater emphasis on promoting the health and wellbeing of individuals and local communities, delivering care more proactively and avoiding unnecessary use of hospitals. For providers seeking to respond to this agenda with the new care models, it means huge changes are needed in how care is delivered and the enablers put in place to support it. Increasingly too, the focus of integration is going beyond a narrower definition of health and care services to encompass more preventative approaches which draw on the full range of assets and services in a place, including services such as housing and employment as well as social and community activity.

It is clear from the findings in this report that in some areas significant impact has been achieved through integrated care approaches. The extent to whether or not
this impact has been achieved is closely related to whether or not there have been any changes in the flow of money and information or in governance arrangements. It may seem obvious, but putting these in place has been hard work in which many have invested sufficient effort. It has also taken a long time.

The highest levels of achieved impact are in areas that have been pursuing integration from 10 to 15 years. While areas that are earlier in their journey may not have achieved as much, these examples serve as a benchmark for what can be achieved and provide a strong learning opportunity. This report, commissioned from Carnall Farrar by the Local Government Association (LGA), synthesises the findings from seven programmes in England. The extent to which integrated care has aspired to and/ or achieved measurable benefit has been examined. This has been reviewed in parallel with whether differences in the design and execution of integrated care contributes to the impact each programme can have. Of particular interest is the focus and care model of the integrated care system and the presence of key enablers such as the information management (including better information governance, sharing and management), payment model (including new
ways of creating incentives for providers such as capitation) and governance arrangements (starting with binding together joint action and leading to new combinations of providers to respond to the opportunities and challenges to deliver integrated care). The report draws out key messages and conclusions that
should be considered locally and nationally within the development of integrated care.

The LGA has long advocated the benefits of integrated, person-centred care as a key vehicle to improve people’s health and wellbeing and experience of care, alongside bringing financial sustainability to the health and care system. The findings in this report highlight how through determined collective and collaborative leadership which engages and empowers everyone in their locality, it is possible to make great strides towards these outcomes. I hope this report informs and inspires us all to achieve the step change our communities deserve.