Integrated care in health policy is very much à la mode. Whilst its ubiquity is self-evident, what it actually is can be difficult to ascertain. This is because of the number of different contexts in which integrated care is deployed, rather than any disagreement about the concept. It is more the case that integrated care is deployed as a panacea for all that ailed the pre-reform NHS. Much of this talk is put forward by assorted vested interests using the ‘idea’ of integrated care as a means of projecting a particular vision of the post-reform NHS. Much of this ‘visioning’ invokes horrific characterisations of outmoded and out-dated NHS, burdened with meeting the needs of an aging population, through approaches to patient care which are ineffective, inefficient and which are far from patient centred
(This video from the Kings Fund neatly sums up this position; I implore you to take the 3:38 minutes to watch this, it will prove ‘instructive’ in terms of this post).
There are many problems with this characterisation, but a central one is that it presents integrated care as the best solution to these problems. However, if we are committed to a model of healthcare based on need, not the ability to pay, then the model of integrated care that is currently up for discussion creates more problems than it solves. In this context integrated care is much more a vehicle for service fragmentation than integration.
For example, Leys describes integrated care as a set of policies and practices intended to cover over the gap between primary and secondary care. This really is the crux of what integrated care is. In his post, Leys talks about integrated care as the model of provision within a post-reform NHS, that is to say, it is to be ubiquitous. Taking a somewhat more ‘pragmatic’ tack, the Department of Health (DH) put forward integrated care as the best possible solution to meeting the needs of elderly population groups (the parallels with the Kings Fund characterisation are self evident). The DH identify key problems within these populations in terms of avoidable admissions and bed blockers, (these are my descriptions, not theirs, the DH talk of people [who] are “sent to hospital, or they stay in hospital too long, when it would have been better for them to get care at home” – I would argue these are essentially the same things). The emphasis is on services that deal with patients with complex needs, that is, patients who require a combination of health and social care, typically personified in policy discussions as frail older people. Why the disjuncture between Leys reading of ubiquity versus the DH’s more measured approach? The devil, I fear, is in the detail.
Integrated care, as an idea is not new. It has been around for years. What is new or novel is the specific type of integrated care being proposed. Basically, integrated care, as it being discussed in the context of the English NHS, is a development from the US Health Maintenance Organisation (HMO) model. It originated in health care insurance and was developed to facilitate planned care pathways. As Leys argues, “It is worth noting that this model in itself is all about planning, not about competition.” This is a crucial difference. The post-reform NHS models of integrated care replace this planning focus with a focus on competition.
Why is this a crucial difference? Put baldly (and this is not say it is without problems) the US model uses the need to plan a care pathway as a means of ensuring integration of services across that pathway, largely driven by a concern over effectiveness of treatment (and associated costs) in an insurance based system. It is the focus on planning that constellates services around the patient, such that planned care best serves a model of integrated care. The English model of integrated care draws from a maxim that competition best serves integrated care.
Under the US model, the responsibility for the planning of the pathway is on the HMO. In the UK model, the responsibility for planning, is on the patients themselves. The implication of this difference is that in the first model, providers might more realistically try and work together with each other, to provide the best (cheapest) planned model of care for the patient. In the second model, a Hobbesian war of all against all prevails, whereby providers are working against any and all other providers to capture the budgets of the individual patients. The planned component of the integrated care model is backgrounded by a more aggressive push for market share. This focus on competition as a driver for integration reflects the perceived need by reformers to open up established statutory NHS provision to private marketeers. Recasting integration and integrated care in a competitive mould enables this door to be opened. The reliance on rhetorics of frail and elderly populations, the looming demographic time bomb and an outmoded and out-dated NHS are simply grist for the privatisation mill, rather than any form of real service improvement.