Why successful integrated care needs to be unequal

By Diane Bell


More than a decade after the Total Place pilots, a ‘whole areas’ approach to UK public services that set out to achieve better outcomes for people at a lower cost, there has been a resurgence in its principles. This time, the focus is on population health and Integrated Care Boards and Systems (ICSs). The Government’s Health and Care Bill says ICSs will build a modern system that delivers better care for our communities while improving value for taxpayers and residents.

Truly addressing population health (defined as an “approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population”) is a big ask for the NHS. Its medical model of care and limited resources make the shift nearly impossible. Despite improved productivity in some areas, the NHS still faces the perfect storm of post-pandemic recovery, Brexit, workforce pressures and the underlying increased demand from a growing and ageing population.

What will it take for the NHS to address outcomes-based care?

Delivering care tactically on the ground – to the standards set by Royal Colleges, the National Institute for Health and Care Excellence, and other similar institutions – is complex and expensive. In the past, when faced with this issue, the NHS has reverted to the familiarity and quick wins of its core ‘one-size-fits-all’ illness-treating service. This leaves the Bill’s duty to reduce inequalities in outcomes (and the resulting requirement for longer-term investments) at risk of falling by the wayside.

The worry, therefore, is whether a re-focus on ICSs and population health will be anything more than a reshuffling of deck chairs that makes little noticeable difference to frontline care delivery.

But what if we took a different perspective on those core NHS principles of ‘need’, and designed care around socioeconomic need as well as clinical need? This isn’t new – the World Health Organization’s classification of functioning, disability and health includes a person’s environment and society. But this challenges the NHS’s traditional view of treatment-based need.

Equal health outcomes doesn’t necessarily mean equal care

Take, for example, two first-time mothers. One has embraced antenatal classes, built a peer network in her local neighbourhood and is confident she knows where to look and who to ask for help if she feels uncertain. The other mother is isolated, unable to get out of her flat easily and has little access to online or other resources. Both will have the same medical needs for themselves and their babies. However, the two mothers’ different socioeconomic situations mean they also need unequal care, with available resources allocated in ways that may contravene national standards, for example, to support their childcare requirements or for postnatal mental health support.

To know how to deliver equitable care requires consolidated data from across whole systems, and for ICSs to be able to interrogate it and use the resulting information to design care effectively and equitably.

The secret of success will be in stretching beyond just bringing together siloed providers and teams around shared ambitions of improving outcomes. ICSs will also need to create different service approaches for different groups of people, even if that flies in the face of current national guidance.

Integrated Care Systems will need to be strong to deliver equitable care

This will require belief and collective strength to stay true to meeting clinical needs in ways that reflect socioeconomic needs. Such strength must endure the pressure from below of challenge to the definitions of individuals’ needs, from around as immediate new priorities inevitably emerge, and from above with regulation and legislation that appear out of kilter with population health.

Are ICSs strong enough to withstand these pressures, put in place the necessary data analytics and make potentially controversial decisions? Only if they realise they need to be, and are empowered to be so. At present, despite the Health and Social Care Bill’s ambitions, I fear too few are.

To truly deliver better population health outcomes through integrated care structures and processes, local leaders must delegate authority to, and provide cover for, front line teams. In doing so, they can provide care unequally but equitably, to ultimately deliver equal outcomes for all.

About the authors

Diane Bell PA healthcare expert

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