Is the NHS becoming more fragmented?
Setting the scene
According to Monitor, the health care regulator, the Health and Social Care Act (2012) focuses explicitly on integrated care. CCGs and NHS England are required to secure health care services that are delivered in an integrated way. NHS England and Monitor have statutory duties to promote and enable integrated care, with CCGs and Health and Wellbeing Boards having statutory duties to promote and encourage delivery of integration within their local areas.
Monitor defines integrated care as:
- being primarily about individual’s experience of care and ensuring better outcomes through co-ordinated, person-centred care and support
- neither necessarily about structures, organisations and pathways, nor about the way that care is funded or commissioned
- referring to how services are configured to deliver seamless care, where the patient or user perspective is the organising principle of service delivery
Monitor states that it has a duty to consider how it can enable integrated care where this improves the quality of services or reduces inequalities of access or outcomes. Monitor is clear that it does not view competition and integration as mutually exclusive and that competition does not need to reduce co-ordination. In their view, integrated care does not need to be delivered by a single organisation but could be delivered by multiple providers including through multi-disciplinary teams or as a result of effective communication with one another.
Monitor recognises that service users often experience health and social care services that are fragmented and difficult to access, with services often being provided by several different health and social care professionals in a number of settings across different providers. Monitor suggests that the reforms offer significant opportunities to promote the interests of patients and service users by ensuring that health and care services are co-ordinated, and that more integrated, better co-ordinated care is a means of improving outcomes.
Is the NHS becoming more integrated or more fragmented?
The Health and Social Care (2012) removed the government’s obligation to provide universal healthcare in England. The Act allows for competition within the NHS and allows for private providers to take over NHS services. A King’s Fund report in 2011 pointed out that successive governments have used competition as a means of improving performance in the NHS, but stressed that one of the concerns about competition is that it can result in increased fragmentation and inefficient duplication of services that can adversely affect quality and outcomes of care. While competition between NHS and private providers already exists in areas such as physiotherapy, hearing tests and dermatology, the new rules mean it could be expanded to many other areas of care.
In an article written shortly before the implementation of the Health and Social Care Act, Marcus Chown pointed out that the Faculty of Public Health’s risk assessment of the Health and Social Care Act had warned of a loss of a comprehensive health service, increased costs, reduced quality of care, and widening health inequalities. He suggested that prior to the reforms, the NHS was integrated, comprehensive, cost-effective and accountable whereas having a mix of providers would be fragmented, expensive and unaccountable.
Fragmentation and patient pathways
Since the Health and Social Care Act came into force, concerns have persisted about the potential fragmentation of services and the impact of this on patient pathways and care. A patient pathway is the route that a patient will take from their first contact, usually with their GP, through referral to the completion of treatment for a particular health condition. Haringey CCG explains that the patient pathway is “developed so that, at each stage, the patient is getting the appropriate care. If that care does not work, the patient will continue on the care pathway to the next stage. Care pathways are designed to get the patient to the appropriate care smoothly”.
Previously, each primary care trust had clearly defined responsibility of providing or commissioning all health services. Following the reforms, the National Commissioning Board holds the responsibility for commissioning primary care, with community and hospital services being commissioned by CCGs supported by a commissioning support service. This makes it more difficult to assign clear lines of accountability and makes fragmented patient pathways more likely.
Baroness Young, chief executive of Diabetes UK, has raised concerns about the impact of fragmentation on patient pathways, in particular for diabetes. In an interview prior to the Health and Social Care Act being implemented, she said that “the fundamental thing for a good diabetes service is an integrated pathway, underpinned by some effective multidisciplinary professional networks. If you’ve got any qualified provider, or a much more diverse market, somebody somewhere has got to make sure that happens in an integrated way”. This, she says, will depend largely on how well the Monitor functions.
In August, Steve Kell, co-chair of the NHS Clinical Commissioners leadership group, warned that an increasingly fragmented system of commissioners and providers makes the development of integrated and patient-centred care more challenging. He said that if the new commissioning arrangements are to deliver then all parts of the system need to work together, stating that "Monitor as a regulator has a lot of information about our local hospital that is not shared with us. We are still fragmented: integrated provision takes a long time; integrated contracting will take even longer. We need to talk to each other".Risks of a fragmented NHS
Concerns continue to be raised about the risks of a fragmented NHS. The chairman of the Academy of Royal Medical Colleges, Professor Terence Stephenson, has said that exposing more of the NHS to private competition could cause a ‘dangerous’ fragmentation of health service and that patients could be in ‘danger from complications’ if the NHS is not joined up. David Lock QC has criticised the re-write of the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013 as not protecting the NHS from privatisation and fragmentation. He was requested by the campaign group 38 Degrees to look into the effects the rewrite of the regulations will have on clinical commissioning groups’ duty to tender contracts for services to private companies as well as NHS providers. He pointed out that the “regulations will almost certainly lead to more services to be put out to tender and will therefore lead to a degree of fragmentation.”
Concerns have also been raised about the increasingly fragmented funding allocation system. The recent King’s Fund report on health resource allocation warns that reforms to health spending (such as splitting public health and NHS funding and the new role for NHS England in resource allocation) risk creating a more complex process with increasingly fragmented decision-making. The report states that the new system of resource allocation is ‘strikingly more fragmented’ and risks undermining other government policies that emphasise the importance of integrated care. It also warns that the system will become increasingly fragmented as the number of commissioners increase, posing ‘substantial risks to a system that needs to integrate around whole care pathways and populations’.
Or can things only get better?
Despite the concerns raised above and the sense that the NHS is becoming increasingly fragmented, the idea of a less integrated NHS has been challenged. Whilst critics of the reforms argue that they have introduced fragmentation through relationships such as commissioning and competition, it has also been suggested that the NHS has developed in a fragmented way since its inception. Thus, the reforms may offer an opportunity to deliver a more integrated service. Certainly, Monitor’s rhetoric is one of promoting more integrated, better co-ordinated care. It will remain to be seen whether they can deliver on this.