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Putting policy into practice: developing locally owned models of care

Ahead of proposed legislative changes, Dr Jonathan Steel, RCP lead fellow for social care, discusses the importance of locally owned models of care in enabling integration.

It has become a truism to say that COVID-19 has further exposed existing fault lines in our community healthcare system, be they chronic underfunding, growing health inequalities or a desperate shortage of clinical staff. Although the pandemic has led to much innovation, the need for more integrated care has never been demonstrated more starkly, especially in the patient journey between secondary and social care.

As the NHS Long Term Plan (LTP) set out, 2021 is the year that all of England must be covered by an integrated care system (ICS) to enable the integrated, patient-centred care that is at the heart of the plan. A great deal of highly localised collaboration has emerged from the pandemic – and the hope is that the legislative proposals due to be brought forward later this year can ‘bake in’ some of that integration.

The RCP responded to a recent NHS England and NHS Improvement (NHSE/I) consultation on proposed legislative changes to strengthen ICSs. We supported the principle of putting ICSs on a statutory footing as a driver for greater integration and work at a local level between all relevant organisations, including the voluntary, community and social enterprise (VCSE) sector. In practice any future changes must be carefully worked through and communicated.

But even with ICSs as statutory bodies, it is not legislation alone that will lead to effective, meaningful collaboration: it is people and relationships. There are so many teams involved in seamless integrated care, from mental health, volunteers, social workers and carers, to GPs, secondary care specialists and district nurses – all of whom should be supported by shared electronic record and medicine management. The ongoing work to roll out ICSs across England must be underpinned by locally created and locally owned models of care.

Models of care allow us to map out a system that makes sense to those who use the system and those who work in it. There is no one perfect model - it has to be place-based, designed around local circumstances with local stakeholders, including patients. It is ultimately about flexibility at the local level based on population need.

This mapping out of a system allows physicians to take a step back from day-to-day processes and see the full extent of the health and care resources available to patients. It helps us to understand the whole system and our place in it, and begin to establish the relationships, that as I have said, are the key to integration and continuity of care.

Some ICSs are more developed than others; where an ICS is new, a model of care is vital. Support should be given to fledgling systems so they can learn from those that are more established and more experienced.

What we also cannot ignore when integrating services is the question of funding and accountability mechanisms. There should ideally be integrated funding with shared budgets across the pathway of care, as well as clarity about where responsibility lies for patient outcomes.

The RCP has made it clear to NHSE/I in our consultation response that greater clarity is needed on the practical implications of legislative proposals. While they have the potential to create positive outcomes, we are all dealing with severe ongoing disruption to services so the case for change needs to be explicitly laid out, including clear benefits.

Legislation may enable greater integration, but success will also rest on locally created and locally owned visual representations of the care system, where we can see what is available to a patient and who we need to establish relationships with to make best use of community assets. It is putting policy into practice that will make the difference.