Developing the Integration Standard further: a framework for action

The Department of Health’s draft Integration Standard study confirms that the journey towards integration is ongoing and evolving.

Building on a national consensus for integration, the development of the Integration Standard can prioritise and accelerate the system changes required to achieve the ambition, but concerted efforts are required nationally, locally and at the point of care.

We suggest conceptually breaking down metrics into national and local objectives.

• National level: shaping the environment for integration at a national level, where the alignment of public policies, financing, regulation and accountabilities is best achieved.
• Local level: here, cross-organisational efforts come together to create a local system for integrated care.
• Frontline level: the frontline delivery of integrated care and how patients/users experience care.

National challenges

The national challenges are appropriate for central government agencies and NHS national bodies (e.g. NHS England, NHS Improvement, Care Quality Commission) to lead and resolve. These actions would help remove the policy and contextual barriers to integration related to financing, regulation, system governance and accountabilities, including:

• addressing the different funding strategies for health and social care, including the ongoing eligibility criteria dilemma
• demonstrating how financial incentives (e.g., contractual levers, different payment approaches) can encourage service integration
• addressing the conundrum of the statutory and regulatory environment conflicting with the aims of cross-organisational cooperation and governance
• setting data interoperability standards and data-sharing protocols
• restating a national framework for integration
• providing a range of examples of ‘what good looks like’ in relation to each of the Standard’s objectives.

Local challenges

The local challenges are best defined nationally but applied locally. They specifically reflect the capabilities of partners to deliver integration, and in many respects they are consistent with the proposed Standard. They recognise that local partners may need guidance and practical support in tackling local barriers to change.

The refinement to the proposed Standard should include effective indicators for measuring:

• the effectiveness of joint working, joint commissioning, strategic alliances and formal networks, including governance frameworks
• the alignment or pooling of budgets and shared contracts, and the use of capitation or other financial incentives that move away from payments for episodic care
• the strength of leadership at local level – in terms of collaboration, including with the voluntary sector, joint problem-solving, etc.
• how new models of care or integrated delivery organisations are providing integrated care
• the effectiveness of discharge and transfer agreements, and protocols for referrals, risk management and rapid response
• data-sharing (integrated IT or interoperability), and the use of data intelligence to drive change and track costs and activity levels poor system working – better systems for detecting risks and early warnings (e.g., rising transfer delays, unplanned admissions, rising costs, etc.)
• the effectiveness of joint workforce training and development, including the development of new roles.

Frontline challenges

The frontline challenges are best understood as measuring the actual delivery of integrated care. They apply primarily to the workers responsible for care, and focus on the point of care, the management of care and especially individuals’ experience of care.

Key issues are:

• the effectiveness of care planning and management, evidence of continuity of care, involvement of users/patients
• the effectiveness of preventative care – put in place support earlier to prevent people’s conditions unnecessarily worsening
• the effectiveness of multidisciplinary teams – how professionals are working together, how well information is shared and communicated, consistent practices and common protocols used
• the benefits from the user’s perspective: breadth and comprehensiveness of services (include mental health), quality of life and wellbeing, maintenance of independence
• personalised care, patient and carer involvement, use of technology
• how well people are supported to manage their own care.