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Looking down the other end of the telescope: why successful integrated care needs to be unequal

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 Systems (ICSs), which have been positioned in the National Health Service’s (NHS) latest ‘Long term Plan’ as the right structures to redesign care processes. The hope is that this combination will, in turn, improve outcomes and value for taxpayers and residents.

Truly addressing population health (defined as inequalities in health outcomes and determinants of health) 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 Brexit, workforce pressures, and increased demand from a growing and ageing population.

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What will it take for the NHS to shift focus from tangible short-term issues to addressing the more ethereal aspirations of the outcomes-based movement? The strategic (e.g. workforce planning) and operational approaches (e.g. redefining geographical team boundaries) required for population health and ICSs to work make sense. But 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 illness-treating service. This leaves preventative care and longer-term investments to fall 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, instead, we took a different perspective on those core NHS principles of ‘need’, and designed care around socioeconomic need as well as clinical need? This is not new: the WHO’s classification of functioning, disability and health includes domains for a person’s environment and society. But it challenges the NHS’s traditional view of treatment.

Take, for example, two first-time mothers: one has embraced antenatal classes, built up a peer network in her local neighbourhood and is confident that 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 have the same needs, as in they are both first-time mothers, and as addressed in national standards. However, the two mothers’ different socioeconomic situations mean they also need unequal care, with available resources allocated in ways that may contravene national standards.

To know how to deliver horizontally equitable care in a vertically equitable way requires not just data pulled together from across whole systems, but for ICSs to know and have the capacity to interrogate and use the resulting information to design care effectively and equitably.

The secret of success for ICSs to improve health for their local population is that they need to stretch beyond just bringing together siloed providers and teams around shared ambitions of improving outcomes. It means different service approaches for different groups of people, even if that flies in the face of current national guidance.

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), 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 that they need to be and are empowered to be so. And, at present, 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 air cover for, their on-the-ground teams so that they can provide care in the (unequal but) most appropriate manner they see fit to ultimately deliver equal outcomes for all.

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