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Chris Ham: Integrated care in Northern Ireland, Scotland and Wales
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Chris Ham: Integrated care in Northern Ireland, Scotland and Wales


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Chris Ham, Chief Executive of The King's Fund, looks at what the health and social care system in England can learn from the experiences of the other countries of the United Kingdom.

Chris Ham, Chief Executive of The King's Fund, looks at what the health and social care system in England can learn from the experiences of the other countries of the United Kingdom.

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  • 1. Integrated care in Northern Ireland, Scotland and Wales Chris Ham Chief Executive, The King’s Fund
  • 2. What was the aim of our study? Different countries in the UK have taken different routes to health care reform Northern Ireland, Scotland and Wales have adopted simpler, integrated structures than England Governments in these three countries have also turned their backs on competition and emphasised the importance of collaboration Each country has sought to promote integrated care in its own way What are the lessons for England?
  • 3. How did we carry out the work? Experts in these three countries were commissioned to write papers using a common format The papers describe the structures and policies in place and their impact They also present examples of innovations in integrated care in each country The drafts were discussed and reviewed by the authors and staff at The King’s Fund
  • 4. Variations on a theme Northern Ireland has had an integrated health and social care system since 1973 with a commissioner/provider split Scotland has had an integrated health care system since 2003 without a commissioner/provider split Wales has emulated the experience of Scotland since 2009 In Scotland and Wales local authorities continue to provide social care
  • 5. Key messages Structural integration brings few benefits unless accompanied by many other changes Northern Ireland has not realised the potential benefits of integrated health and social care Scotland has made most progress for reasons outlined later Wales has only moved to an integrated health system recently and it is too soon to make a proper judgement
  • 6. What factors matter other than structural integration? 1.Coherent policies that promote and support integrated care – including a national performance framework and a single outcomes framework 2.Governance arrangements that enable different organisations (especially local authorities and NHS bodies) to work together to develop joint integrated care strategies
  • 7. Lessons learned 3. Political, managerial and clinical leadership at all levels that ensures a clear and consistent focus on integrated care 4. Organisational stability to avoid distractions and delays 5. Willingness to challenge and overcome professional, cultural and behavioural barriers to integrated care within the NHS and between the NHS and social care
  • 8. Lessons learned 6. Commitment to integrated care as a policy priority for government as a whole 7. Maintaining this commitment over sufficiently long period to enable policies to have a measurable impact 8. Financial support and flexibilities to enable introduction of new models of care (eg, Change Fund in Scotland and ‘invest-to-save’ schemes in Wales)
  • 9. Lessons learned 9. Information sharing both within the NHS and between health and social care 10. An ability to manage the differences and tensions that arise when public services are organised differently (eg, in Scotland and Wales, there is commissioner/provider separation in local authorities but not in NHS)
  • 10. What are the implications for England? The government will announce a programme of integrated care pioneers in the autumn It is also developing a plan for vulnerable older people which will emphasise the need for integrated care The challenge will be to move towards virtual integration in England as structural change is not on the agenda This could be an advantage if policy-makers are willing to heed the lessons from elsewhere
  • 11. Implications (2) Policy-makers in the Department of Health and other national bodies should study the lessons we have identified and act on all of them There should be a long term commitment to integrated care across government Policy barriers should be removed or amended eg, perverse incentives like payment by results Health and wellbeing boards could play an important role The allocation of £3.8bn in the spending review could help to galvanise change
  • 12. Implications (3) Much will depend on alignment of political, managerial and clinical leaders to bring about change There needs to be a strong and shared commitment that integrated care is the right route to take The risk of organisations looking after their own interests rather than working together must be managed Performance management and outcomes frameworks need to be aligned
  • 13. Finally Integrated care is the right thing to do but it is also hard to do This is why successful examples are still few and far between A transformation is needed to develop the services required for an ageing population and to meet the challenge of multimorbidity Persistence over time and committed leadership are key ingredients