- In Greater Manchester, where integration is most advanced, results have been generally poor.
- In particular, despite a £450m cash injection, there has been a 65% increase in delayed transfers of care – the benchmark for whether health and social care systems are working properly together.
- Outcomes in West Yorkshire, where integration is under direct NHS supervision, have been better, especially in terms of delayed transfers of care – but there is still no evidence of substantive overall improvement.
- There has also been an alarming rise in emergency readmissions, and in the number of senior managers hired.
- Across the 13 pilot areas, delayed transfers of care have increased by 24% since 2016, against a 9% increase in other NHS trusts.
- The CPS argues that Government should prioritise bottom-up integration and collaboration, as well as gathering more evidence from existing pilot schemes, rather than pursuing another top-down reorganisation of the NHS on an insufficient evidence base – especially given the strain the health service is already under due to the pandemic.
The NHS in England is about to undergo another seismic reorganisation, with the new Health and Care Bill dividing the service into 42 Integrated Care Systems (ICSs) in order to drive integration and collaboration in health and social care.
However, the evidence base for such a transformation is alarmingly thin, as highlighted by the National Audit Office in 2017 when they warned that the Government had ‘not yet established a robust evidence base to show that integration leads to better outcomes for patients.’
‘Is Manchester Greater?’, by the Centre for Policy Studies (CPS) think tank represents the first attempt to establish such an evidence base, scrutinising the performance of pioneering integration schemes in Greater Manchester, West Yorkshire and then more broadly across England in the years before the pandemic. It attempts to evaluate their performance compared both to other areas of the country, and the original targets set.
The report finds that, in Manchester, there was a 65% rise in delayed transfers of care under devolution – far higher than the national average – and generally weaker or unchanged performance on other health outcomes. In fact, the research could not identify a single target set out in Manchester’s own plan that the devolved system was on course to meet before the pandemic struck.
The data also shows a significant decline in productivity, with a 9% increase in the size of the region’s NHS workforce relative to its population, and a 23% increase in the number of senior managers.
This poor performance came in spite of the upfront £450m transformation fund, which, if repeated nationwide, would lead to a staggering £11 billion funding increase for the NHS and social care, almost the equivalent of the entire NHS budget increase in 2021/22.
The report also scrutinises the performance of the West Yorkshire and Harrogate Health and Care Partnership, a more recent creation but more typical of what the ICS model will look like in practice. The evidence here was more positive than in Manchester, in particular in terms of delayed transfers of care – but emergency readmissions to hospital had risen to 14.4% by 2019-20, overtaking the national average. Overall, there was no evidence of significant performance improvements. And again, there had been a significant increase in healthcare bureaucracy, with a 20% increase in managerial staff since 2016.
Finally, the report compares the results across the 13 pilot integration areas on a range of metrics. The most alarming finding was that delayed transfers of care increased by an average of 24% between 2016 and 2020, weighted for population, whereas the figure was just 9% in the rest of the NHS.
The CPS is therefore calling on the Government to drop plans to put ICSs on a statutory footing until there is a more robust evidence base. It suggests that the 13 more advanced pilot schemes be run until 2026 (to provide a holistic picture, over a decade, of the impacts of integration). In other areas the local healthcare bodies should be encouraged to further develop local referral and care pathways, to streamline patient flows between different care settings, and to experiment with new and better approaches to integration, competition and collaboration.
The CPS is also for ICSs and NHS England to collect and publish more data on health outcomes, creating a consolidated ICS database which could help policymakers and enable citizens to hold their ICS leadership to account and push back against poor outcomes.
Karl Williams, report author and Senior Researcher at the CPS, said:
‘The Government’s determination to tackle the long-term problems facing health and care provision is welcome, but it is important to take the time to get things right.
‘Everyone seems to be in such fervent agreement that the ICS model of integration and collaboration is the future of the NHS that hardly anyone appears to have looked properly at whether this approach works in practice. This report does just that – and the data does not support the speed or scale of the planned changes.
‘Ministers need to take a step back and let the pilot schemes run their course so we can properly evaluate their success. Now is not the time to push through costly and disruptive reforms that are not supported by the data, especially given the current pressures on the NHS and its staff – which as widely reported, is already facing a record backlog of more than five million people awaiting treatment because of the pandemic.’