The National Audit Office warns that progress with integration of health and social care has, to date, been slower and less successful than envisaged and has not delivered all of the expected benefits for patients, the NHS or local authorities. As a result, the government’s plan for integrated health and social care services across England by 2020 is at significant risk.

In the face of increased demand for care and constrained finances, while the Better Care Fund, the principal integration initiative, has improved joint working, it has not yet achieved its potential. The Fund has not achieved the expected value for money, in terms of savings, outcomes for patients or reduced hospital activity, from the £5.3 billion spent through the Fund in 2015-16.

Nationally, the Fund did not achieve its principal financial and service targets over 2015-16, its first year. Planned reductions in rates of emergency admissions were not achieved, nor did the Fund achieve the planned savings of £511 million. Compared with 2014-15, emergency admissions increased by 87,000 against a planned reduction of 106,000, costing £311 million more than planned. Furthermore, days lost to delayed transfers of care increased by 185,000, against a planned reduction of 293,000, costing £146 million more than planned.

The Fund has, however, been successful in incentivising local areas to work together; more than 90% of local areas agreed or strongly agreed that delivery of their plan had improved joint working. Local areas also achieved improvements at the national level in reducing permanent admissions of people aged 65 and over to residential and nursing care homes, and in increasing the proportion of older people still at home 91 days after discharge from hospital into reablement or rehabilitation services.

There is general agreement across the health and social care sectors that place-based planning is the right way to manage scarce resources at a system-wide level. However, local government was not involved in the design and development of the NHS-led sustainability and transformation planning programme. Local authorities’ engagement in the planning and decision making phase has been variable, although four sustainability and transformation planning areas are led by local authority officials.

The Department of Health and the Department for Communities and Local Government have identified barriers to integration, such as misaligned financial incentives, workforce challenges and reticence over information sharing, but are not systematically addressing them. Research commissioned by the government in 2016 concluded that local areas are not on track to achieve the target of integrated health and social care by 2020.

Today’s report also found that NHS England’s ambition to save £900 million through introducing seven new care models may be optimistic. The new care models are as yet unproven and their impact is still being evaluated. According to the NAO, while the Departments and their partners have set up an array of initiatives examining different ways to transform care and create a financially sustainable care system, their governance and oversight of the initiatives is poor. The Integration Partnership Board only receives updates on progress of the Better Care Fund with no reporting from other integration programmes.

In addition, the NAO found no compelling evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity. While there are some good examples of integration at a local level, evaluations have been inhibited by a lack of comparable cost data across different care settings, and difficulty tracking patients through different care settings. The NAO today reiterates its emphasis from its 2014 report on the Better Care Fund that there is a need for robust evidence on how best to improve care and save money through integration and for a co-ordinated approach.

The public rightly expect the highest standards of behaviour in the NHS, and we take our responsibility as custodians of taxpayers’ money very seriously. Decisions involving the use of NHS funds should never be influenced by outside interests or expectations of private gain, but we recognise that conflicts of interest are unavoidable in complex systems.

NHS staff need to be empowered to use good judgement in managing conflicts of interest effectively, and need to be safeguarded so they can continue to work innovatively with partners whilst also providing transparency to the taxpayer.

​

On 9 February 2017, we issued new guidance on managing conflicts of interest in the NHS. This guidance:

• introduces common principles and rules for managing conflicts of interest

• provides simple advice to staff and organisations about what to do in common situations

• supports good judgement about how interests should be approached and managed.

Take a look at the guidance: Conflicts of Interest in the NHS – Guidance for staff and organisations

The guidance comes into force from 1 June 2017 and is applicable to the following NHS organisations:

• Clinical Commissioning Groups (‘CCGs’) via the statutory guidance to CCGs issued by NHS England

• NHS Trusts and NHS Foundation Trusts – which include secondary care trusts, mental health trusts, community trusts, and ambulance trusts

• NHS England (through our Standards of Business Conduct).

The guidance does not apply to bodies not listed above (i.e. independent and private sector organisations, general practices, social enterprises, community pharmacies, community dental practices, optical providers, local authorities).

However, we invite these organisations to consider implementing the guidance as a means to effectively manage conflicts of interest and provide safeguards for their staff.

This report reveals that commissioning bodies are not delivering value for money in three key areas.

Commissioners are failing to focus on outcomes that matter to service users. Service success is measured by output (such as the number of hip operations delivered) and inputs (the cost of each operation) rather than outcomes (sense of wellbeing). Commissioners feel they do not possess the skills to design outcomes-based contracts and a risk-averse attitude to failure is a barrier to commissioning for more abstract goals.

​

Fragmented commissioning bodies stand in the way of integrated services that meet users’ needs most effectively. Ambiguity of responsibility for designing services leads to gaps in delivery. In other instances, services are duplicated, with HM Treasury putting the cost of similar interventions being delivered at £100 billion in 2010. Prevention is undermined where commissioners are not responsible for the failure to stop issues – such as illness or crime – occurring.

Devolution of commissioning to local areas is not happening in practice, with a one-size-fits all approach creating a postcode lottery across in healthcare, welfare-to-work and probation services. The UK remains one of the most centralised advanced economies. Whitehall commands dictate spending in areas such as healthcare, despite local commissioning bodies being designed to deliver locally tailored care. This is undermining the transformation and integration of public services. Other central aims create perverse incentives, with central targets dictating the actions of frontline professionals.

​

The Government’s aims of commissioning integrated, locally tailored services that meet the outcomes of service users are laudable. The current commissioning model is failing to achieve all three however, to the detriment of service users and taxpayers alike. Recognising this is the first step to designing a new commissioning framework capable of delivering services that meet the complex needs of users, wherever they may live.

Health care costs are heavily concentrated among people with multiple health problems. Often, these are older adults living with frailty, advanced illness, or other complex conditions. In 2014, the New York–based Commonwealth Fund, a private, independent foundation, established the International Experts Working Group on Patients with Complex Needs through a grant to the London School of Economics and Political Science. The group’s purpose was to outline the prerequisites of a high-performing health care system for “high-need, high-cost” patients and to identify promising international innovations in health care delivery for meeting needs of these patients. Drawing on international experience, quantitative and qualitative evidence, and its members’ collective expertise in policy and program design, implementation, and evaluation, the international working group sought to articulate the principles that underpin high performance for this complex population in health systems around the world.

What follows are the group’s top recommendations based on these principles. All 10 present challenges, with some requiring profound paradigm shifts—for instance, away from disease-specific care delivery and toward more patient-centered approaches, or away from the single-provider model and toward cooperation and teamwork. Their implementation, however, has the potential to transform care and quality of life for millions. The selected international models that follow the recommendations represent some of the promising frontline care innovations that illustrate the principles laid out here.

The guidance – Confidentiality: good practice in handling patient information – comes into effect from Tuesday 25 April 2017.

Revisions have been made to the guidance, last published in 2009, following an extensive consultation exercise. While the principles of the current GMC guidance remain unchanged, it now clarifies:

The public protection responsibilities of doctors, including when to make disclosures in the public interest.

The importance of sharing information for direct care, recognising the multi-disciplinary and multi-agency context doctors work in.

The circumstances in which doctors can rely on implied consent to share patient information for direct care.

The significant role that those close to a patient can play in providing support and care, and the importance of acknowledging that role.

The GMC has also published a decision-making flowchart and explanatory notes to show how the new guidance applies to situations doctors may encounter and find hard to deal with, such as reporting gunshot and knife wounds or disclosing information about serious communicable diseases.

Charlie Massey, Chief Executive of the General Medical Council, said: ‘This refreshed, revised and restructured guidance on confidentiality will help doctors better understand their responsibilities when handling patient information in their everyday practice.

‘We know doctors want more support and guidance on some of the complexities of confidentiality, and so as well as the revised guidance we are also publishing some supporting explanatory notes. We will produce additional helpful materials for doctors when the guidance comes into effect in April.’

The GMC’s new app – My GMP – signposts to the revised guidance today. When the guidance comes into effect in April, additional resources and case studies will be published for doctors and patients.

The Patients Association launches report on patients’ poor experiences with the Parliamentary Health Service Ombudsman

Today (Thursday, January 12, 2017) the Patients Association has released a report on the Parliamentary Health Service Ombudsman (PHSO). The report reveals that a significant number of patients and family members who submit complaints to the PHSO feel that they receive a poor quality service.

The Patients Association’s national Helpline received nearly 300 calls between May and October 2016 from people who had concerns about the way their cases were being dealt with by the PHSO.  An investigation into the nature of the calls has revealed the findings contained in this follow-up report.

A draft version of this MCP Contract has now been published, together with a set of supporting documents that provide additional information and we are inviting feedback on these. Although the documents concern the MCP model, many of the principles are transferable to other new models of care.

The draft MCP Contract is the product of intensive joint work with a number of vanguards with whom we are co-developing the approach to ensure that the Contract will help facilitate local plans.

The way that health and social care is delivered is changing, and CQC want to develop their approach to respond to emerging new care models. They have now carried out a comprehensive inspection of every NHS trust in England and  propose to use this understanding together with improved systems for gathering intelligence to move towards more targeted inspections for NHS trusts. Alongside this consultation, they are consulting jointly with NHS Improvement on our approach to leadership and use of resources in NHS trusts.

These plans reflect the priorities they set out in their five year strategy for a more targeted, responsive and collaborative approach.

​

In the past week, CQC has published a further 107 reports on the quality of care provided by GP practices that have been inspected by specialist teams of inspectors. Under CQC’s new programme of inspections, all of England’s GP practices are being given a rating according to whether they are safe, effective, caring, responsive and well led. The Chief Inspector of General Practice has found another 75 practices to be Good, 19 to Require Improvement, three to be Outstanding and three to be Inadequate following recent inspections by the Care Quality Commission. Seven reports were focused inspections which are not rated. The total number of practices rated Outstanding is now 209. The total number of practices that have exited Special Measures is now 81.

The NHS England conflicts of interest cross system task and finish group has published proposals for change to the way in which conflicts of interest in health are managed, for consultation. The consultation period is open from Monday 19 September 2016 to Monday 31 October 2016.

It is some sixteen years since Sir Liam Donaldson’s report into patient safety ‘An organisation with a memory’ was published. In this report, he was critical of an NHS that had no systemic way of identifying and learning from mistakes to reduce risk for future patients.

​

Since then, various high-profile inquiries and reviews have consistently identified similar themes, including the need for a standardised investigation process and a change in culture whereby staff feel they can report mistakes and adverse incidents without fear of retribution. Some improvements have been made. However, it is clear that, despite long-standing calls for an open learning culture in the NHS, barriers remain.

As part of the NHS England CCG Improvement and Assessment Framework, CCGs are required to submit quarterly and annual self-certification returns to demonstrate compliance with the requirements of the revised statutory guidance on managing conflicts of interest for CCGs.  View details of the self-certification proformas and guidance on the submission process

This briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review.

The briefing provides a summary of our findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.

In June 2016, NHS England published revised statutory guidance on managing conflicts of interest for clinical commissioning groups.