Integrated Care Should Not Be Judged by Its Effects on Hospital Activity

I loved ICIC26. There was a refreshing mix of topics, sessions and participants; I had a great time interviewing Dr Minal Bakhai about neighbourhood working; and, squirming aside, I even enjoyed watching myself on the 'bloopers reel' for the conference promo video.

And yet...

I detected a slightly depressing undertow in some of the sessions and conversations. Perhaps I'm putting this clumsily or a bit crudely, but I'd express what I heard as being that ‘integrated care has failed’.

Not ‘failed’ as in ‘comprehensively led to nothing of use or note’ – but ‘failed’ as in ‘not met the hard measures set for it by policy makers’.

And, getting more specific, it seemed to me that what people expressing this sentiment meant was that integrated care has failed to alter the growth in hospital activity.

The English NHS is, sadly, no stranger to this sentiment. Its most prominent integrated care programme goes under the banner of ‘Neighbourhood Health’. And, while this initiative clearly includes many other measures – which has been welcomed by well-respected policy analysts – ‘reduction of hospital activity’ is prominent in the mix of desired results.

In some respects this is to be welcomed. There is evidence to support the view that neighbourhood working can help make the NHS less hospital-centric.

My team – the Strategy Unit – has been straining every analytical sinew to illuminate which kinds of activity can be mitigated by community-based support. We are working with local organisations to apply these insights in practice. And we are advocating for relational continuity in primary care, partly as a way to reduce demand on hospitals.

But there are clear limits. And I see a real danger: those of us supporting community-based integrated care should not accept sole responsibility for reducing hospital activity. This should not therefore be the main metric to assess the merits of integrated care.

This is for a simple, but poorly understood reason. In short, and again putting it crudely: the main determinant of hospital activity is, well, hospital activity.

Plenty of evidence shows this. For example, our recent analysis for the NHS ‘New Hospitals Programme’ showed that the growth in hospital activity between 2011 and 2019 was explained more by medical innovation than population need. Our previous analysis showed that innovation drives hospital-based activity in a way that is simply not true for primary and community services. And an even earlier analysis showed how increased diagnostic activity in emergency departments led to overcrowding and longer waiting lists.

Reducing hospital activity is, in some senses, a laudable goal. It has therefore been a consistent goal of English health policy for many decades.

The fact that it hasn’t been achieved is not because of the ‘failure of integrated care’. It is because of the radical success of innovation and speciality-based care: a success which has, in some senses, then gone on to cause its own problems.

Addressing this will require policy and programme efforts on many fronts. And forthcoming Strategy Unit analysis will show the most effective mechanisms for mitigating hospital activity. (Spoiler alert: de-adoption by hospitals is more effective than community-based prevention). Bringing about a less hospital-centric NHS is the work of many: it is not the responsibility of Neighbourhood Health. Nor should it be the yardstick for it.

I also left the conference hopeful. I saw many examples where integrated care is making a clear and compelling case. Very often it was a case made in terms that seemed reasonable. What I wanted to say was this: keep making this case – and be careful how far you accept the terms set by policy.

Integrated care creates value on many fronts. It cannot – and should not – be reduced to a simple, and only partly appropriate, measure.

Perhaps spreading this message (and evidence) would help lighten the mood in the integrated care community?