Niamh Lennox-Chhugani presents to the UK House of Lords Integration of Primary and Community Care Committee

Our Chief Executive, Dr Niamh Lennox-Chhugani, was honoured to be invited to give evidence to the UK House of Lords Integration of Primary and Community Care Committee on 26 June. You can see the evidence session full on Parliamentlive.tv.

The Committee was set up in March 2023 to explore improved ways to integrate the delivery of effective primary and community care services. The Committee is considering the challenges facing the sector and any barriers preventing further integration. The success of existing models of integration are being examined, including the role of Primary Care Networks and Integrated Care Systems. The Committee is also looking at access to primary and community care services, accountability and decision-making.

Niamh shared IFIC’s experience of international research and practice, responding to the question “what are the strengths and weaknesses of the English approach to integrating primary and community care?”. She highlighted the caveat that internationally there are different definitions of scope related to primary care, community care and what is being integrated. Organising models are different which makes direct comparison also challenging. Some international systems include social care in their model of primary care. Some include it in their model of community services. Others provide it separately under the welfare system. At IFIC we talk about 4 core elements of integrated care – care coordination, care continuity, person-centred and community-centred. This helps to the focus away from an optimal model – what constitutes integration is highly context dependent.

That said, the evidence we see on the strengths of English approach include a clear national policy certainly from 2014-2019 grounded in the NHS Five Year Forward View and the establishment of the New Care Models programme to test new models of at scale systematically with embedded evaluation.

On the limitations, we see evidence of a lack of clear purpose and goal for integration that has been sustained over time[1], with an increasingly narrow focus on avoiding admissions to hospital over the period of implementation. We also see an over-reliance on structures and contracting particularly in relation to the inclusion of primary care as currently practiced in the English system.

Expanding on this evidence, Niamh shared written evidence with the Committee that gave an example of a system taking a different approach, that of Flanders in Belgium. They have been working on delivering integrated community care since 2010 and started with political commitment to strengthen three elements together – health care, social care and well-being – in an integrated framework. They then engaged in an inclusive planning approach with primary and community care providers to map out the reform journey. They adopted a wide definition of primary care that goes well beyond general practice. They set up the Flemish Institute of Primary Care to support capacity and capability building and invested in information systems to support care coordination as well as putting new governance structures in place. The next step is bringing well-being and prevention more strongly into the primary care zones over the next five years.

When asked about how the outcomes of policies to promote integration in England compare with those in other systems and what lies at the root of these differences, Niamh outlined IFIC’s research which has shown that the most impactful levers that are in the hands of policy makers include, provision of the legislative framework for new models of integrated governance, new payment and reimbursement models or at a minimum changes to the current system that reinforce fragmentation, providing investment in digital technology to support shared information and new models of care delivery, and performance reporting and improvement frameworks that focus on all 4 elements of the quadruple aim, not just cost.

Her written evidence to the Committee further detailed that there is no health and care system that is not struggling with one of more of these. Those that are more mature, have been on the road for some time, e.g. Flanders since 2010 and Slovenia since 2002. Both systems still have gaps but a cumulative implementation programme to address these. The funders of new approaches required systems to conduct evaluations of new care models which generated evidence that then fed back into the system to support decision making about scaling up.

So the most visible outcomes of policies to promote integration in England have been more focused on local models of care and ICB level enablers. The provision of legislation to support the set up of ICBs is one visible outcome. Going back to the core elements of integrated care, care coordination, care continuity, person-centred and community centred, some of that has been lost in the last few years in the focus on structures at ICB and place level. There is still a lot happening at the front line in testing out approaches to care integration that are inclusive of social care and community organisations but these are still limited in scale even at place level and rarely funded for the long term placing significant uncertainty burden on community organisations involved.

Wrapping up, Niamh recommended one thing that the UK Government do to better integrate the health service in England as aligning the funding for health and social care to transform behaviours around the system which are currently incentivised to shift the funding burden from one part of the system to another – from primary to secondary care, from health to social care, from prevention to curative care and so on.

But also to remember why this is being done. The Five Year Forward View in 2014 built on the learning from the Integrated Care Pioneer Programme in England and was very clear that the goals of integration were

• a greater focus on prevention to reduce inequalities and provide the population with the basis on which everyone has opportunities to contribute
• more partnerships with community organisations to ensure that the needs of local populations are at the centre of planning and provision and a better experience of care coordination and continuity.
• A system that meets the needs of people with chronic and multiple conditions by reducing fragmentation to improve the experience of care and outcomes.

[1] Lewis et al. Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?. International Journal of Integrated Care, 2021; 21(4):5, 1–10. DOI: https://doi.org/10.5334/ijic.5631

July 2023

Dr Niamh Lennox-Chhugani

Chief Executive

International Foundation for Integrated Care (IFIC)