Exclusive: Reconfiguration - How can we make the most of opportunities for integration?

After years of policy debate, it seems that the time for reconfiguration in many parts of the NHS has come, writes David Bennett, chairman and chief executive of competition regulator Monitor.

David Bennett: 'Change must include a significant move towards the better integration of services.'

This is no longer a subject for seminars and conferences but a recognised path to sustainable healthcare that needs to be put into action.

Recent statistics produced by the Foundation Trust Network show that 90% of senior NHS managers believe there is a need to change the way services are delivered at a local level and 78% believe that reconfiguration would improve outcomes for patients.

Decision to reconfigure

Once the decision to reconfigure is taken, the question to ask is how this should happen? Ultimately, it is important that reconfigurations are approached in a way which looks not just at making services more sustainable but also advances the patient journey. This is why local commissioners and providers must follow underlying principles for reconfiguration based on a solid clinical evidence base, support from GP commissioners as well as from the local community, and furthering the capacity for patient choice.

A recent think tank report has found the inherent tendency of NHS organisations to operate in isolation to other services around them has led to a rise in the number of unnecessary hospital admissions – a cost to patients as well as to the health services.

We believe this raises the urgency of achieving integration - within local primary and acute services as well as across health and social care - and reconfiguration represents an important opportunity to do this.

Torbay example

That this approach provides real and tangible benefits for patients is borne out by the example of Torbay where the creation of locally based integrated health and social care teams, with a single manager and a single point of contact for patients and service users, helped improve care for frail older people, reduced the use of hospitals and care homes and minimised the delay of transfers of care saving money and increasing quality.

Unfortunately, examples like Torbay are currently the exception rather than the norm. Whilst there may be a desire to reform local healthcare systems to help patients move more freely across health and social care services, this change has not happened in any widespread or concrete way across the NHS. Reasons for this inaction range from difficulties in sharing records electronically and difficulties transferring funds between health and social care, to concerns about how performance targets are measured, who holds responsibility for planning and coordinating care, and who is ultimately accountable for the patient’s treatment. Sometimes it boils down to the fact that people are used to working a certain way, often this means a habit has developed of working in isolation, and this is a very difficult culture to change.

Monitor’s new role

So what can be done to address these barriers and help local decision makers make the right choices when it comes to reconfiguration? As part of its new role, Monitor has a duty to enable integration – and this is a duty which we take extremely seriously. We believe that in order to reconfigure services in a way that achieves integration you not only have to change the way that systems, pathways and organisations operate but you must create a coordinated care system that is flexible enough to meet the needs of individual patients and robust enough to safeguard the sustainability of health and social care provision at a local and national level.

The measures we are putting in place will help commissioners and providers do this. In our new role, Monitor will require licence holders to avoid behaviours that would be detrimental to enabling integrated care. Through our pricing strategy we aim to remove obstacles that prevent patients moving smoothly from one service to another by creating incentives that promote quality and meet patient needs.

Developing outcomes-based payment models

In the short term this means raising awareness amongst commissioners about the flexibilities that exist under Payment By Results, in the longer term it means developing outcomes-based payment models, where providers are incentivised to ensure that the patient receives the best service for their individual needs – wherever that may come from. These drivers to integration need to be supported by a coordinated effort between ourselves, the NHS Commissioning Board, the Local Government Association and the DH to produce the right kind of advice, tools and guidance to empower local NHS leaders to make the bold decisions necessary.

Ultimately, however, the onus is on local decision makers to make sure reconfiguration gives them the desired outcome. The acceptance by providers of the need to reconfigure services means that the possible options for local commissioners are wide ranging. But in order to achieve the cultural approach necessary for services to work in an integrated way, they must work with other parts of the local NHS to gain their support from the start.

In particular this means working with their local communities to make sure they are making decisions that are in the best interest of patients today and in the future. In fact, to make change palatable we must make sure that patients can see the benefits for them in a tangible and immediate way.

The NHS is facing up to the pressures on the health and social care systems which have created the imperative to change. It is my belief that this change must include a significant move towards the better integration of services, and better integration can only be achieved if everyone involved in that change believes in the benefits it will deliver for the community.  

* David Bennett will give a keynote address at the NHS Alliance conference on The Road to Integration on 22 November.

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