The first of the great London hospitals was founded by Henry I’s jester, who on a pilgrimage to Rome dreamt feverish dreams of St Bartholomew. In his dreams, he was instructed to dedicate his life to caring for the poor.
As soon as he got back to London he implored Henry to build a huge new building, just for that purpose. He agreed. That hospital is now called St Barts.
The hospital was built outside the city walls, so pilgrims, travellers, waifs and strays could be checked for communicable diseases before they entered London itself.
That splendid isolation was so successful that it became something of a trend for subsequent hospitals. It meant that the monks and nuns who staffed the hospitals were shielded from the evil temptations of the city, and it helped to protect London from epidemics and undesirable characters.
The hospital treated its patients in two ways. Firstly, it tried to heal them physically, from whatever ailments they had. And secondly, it tried to heal them spiritually, by encouraging them to take confession, pray regularly and live a life of virtue.
You might almost say that that was a sort of prototype integration – treating people as people rather than as mere bag of medical symptoms.
Good integration exists
Good integration has changed a lot in the intervening 900 years. And yet the best healthcare is still personal.
Look at what is happening in Leeds with adult social care.
They are changing the social care market by encouraging corporate responsibility, volunteering, and flexible services.
They give grants of up to £10,000 to support social enterprises all over the city. And then they make sure that those social enterprises can flourish by aligning them with the private and third sector groups.
That means people in Leeds can now access a more diverse and well-rounded selection of services that is growing all the time.
So instead of being stuck of the phone for hours, trying to find someone to come and dress a wound, provide meals or prescribe some medicines, local organisations all talk to each other to provide that help
There are good examples elsewhere in the country too. In Northumbria, the local FT has linked the acute hospitals, community services and social care.
In Cumbria, community services and GPs have made links to hospitals.
And in North East Lincolnshire, the care trust has developed far better links between services over the last few years
The paradox is that although everyone recognises the need for this kind of personal treatment, it does not happen everywhere. In fact I think it is still the exception rather than the rule. And even in those places that have made good progress, none to my knowledge have yet developed a fully integrated system of care.
So I want to get to a position where I don’t have to eulogise a few places, because everyone does it just as well as they do or even better.
The current situation
At the moment, that is a long way off.
As it stands, care is fragmented.
The irony of the debate over the health reforms was that people expressed concern about a risk of fragmentation of services. Yet we had that with a vengeance before: mental health split from physical health, primary from secondary and healthcare from social care. Patients tossed between services with little or no continuity. The same was true of links between health and care on one hand, and housing, employment, and other services on the other.
That has to change.
For instance, we know that financial incentives drive behaviour – and we know that paying hospitals each time a patient is admitted encourages more activity. Hospitals are rewarded for getting patients in and out, but not for giving them good care.
Seriously ill people fall between the gaps. Too often, patients get poor treatment.
Health and care professionals know this. They are all too aware that things don’t work.
They are incredibly frustrated by the way the system stops them providing the kind of care that people want.
I’m sure everyone in this room, whether you are a doctor or a manager or an academic or a carer or anyone else - I’m sure everyone in this room could point to a part of their local health and support system where things don’t work as smoothly as they should. Maybe it’s poor communication between community care team and GPs, or IT systems that are only available to a tiny number of people, or a system of discharging patients that pays too little heed to their needs
Too often the system looks dysfunctional and the pressures are growing inexorably:
Ambulance Trusts trying to cope with growing demand,
Patients waiting for discharge because no arrangements are in place for when they get home, and
Hospitals full of frail elderly people with dementia – an estimated 25,000 hospital inpatients have dementia, a quarter of the total capacity. And a recent study showed that 97% of nursing staff said that they care for someone with dementia at least some of the time.
Unless we get everyone working together, stop duplicating effort and start keeping people out of hospital, then the NHS could buckle under that pressure.
Take one of the touchstone issues over the last few months – the pressure on A&E departments.
At the moment, wards are crowded with people with long term conditions are there because their care has broken down. A crisis has occurred which might have been avoidable. In time, wards do not have the space to take people from A&E departments. Ambulances are then log-jammed outside the front door because they can’t discharge people into A&E. As people get older, that situation gets worse.
Four million more people use A&E every year compared to a decade ago. And GP out of hours services have their own problems.
And there is one story in particular, Mid Staffs, that reminds us that poor care and hospitals under pressure is a matter of life or death.
I want to be very clear about this. We cannot afford to allow this to continue.
Without a different approach, which focuses on preventing ill health and on maintaining the wellbeing of those with long term conditions the NHS will no longer be an institution that we can count on when our families need care. It will be branded with perpetual risk, perpetual underachievement and, ultimately, perpetual failure. And we will see another Mid Staffordshire.
Straining every nerve to maintain the system, shaking off cost further and further but ploughing on regardless is not an option.
Those are strong words. But I do not believe that they are misguided or overly dramatic.
In fact, I think that this is the right place to say these things.
The potential of integration
The Kings Fund has vigorously promoted integration. I know health ministers have quoted Chris Ham [Kings Fund chief exec] for years, tirelessly repeating his statement that integration is the challenge that will define modern healthcare in the way that waiting times did not too long ago.
I want to thank you all for that. Despite the negligible coverage that integration gets in the press, I think we all know how important it is.
Inside the treasure chest of integration lies much of the solution to challenges that will define the future of the NHS: a population that is getting older, drugs that cost more than ever, rising expectations and a health and support system that is only just keeping its head above the water. Integration will help unravel some those problems.
For example, better integration would mean better care for the 15 million people with a long term condition. Addressing loneliness and isolation, reducing falls, identifying people at risk of relapse, discharging people more quickly and safely, getting them more suitable care and support.
And let’s not forget the potential for integration to squeeze more value from every pound we spend.
Costs go up and up and up every year.
At the moment, a disproportionately large slice of the NHS budget goes on older people and those with long term conditions. Those two groups are getting bigger – but they are also two groups who will really benefit from integrated care. That link is too important to overlook.
Spending is protected under the coalition but at the same time we can no longer afford to throw money at problems. We have to work smarter.
Using integration to cut emergency readmissions, for example, could save £132m a year by itself. Cut delayed discharges as well and that reaches half a billion pounds.
And if ‘whole place’ community budgets happened everywhere, the savings could run as high as £5bn.
And that’s not even counting the most important thing: better care.
The future – encouraging integration
I came here last week to talk about four things that are stifling integration: spending money poorly, unambitious leadership, a lack of capability and slowly-moving evidence.
I spoke about how the bold pioneers of integration can help address all four by providing living, breathing proof of what integration can do.
And it gives me the greatest of pleasure to announce today that we are inviting areas to step forward to be those pioneers.
The successful applicants will be announced in September, after which we will work with them to push the boundaries of integrated care.
In those pioneer sites, commissioners and providers across health and social care will work together in one big push, unconstrained by the traditional, fragmented way of working.
Good ideas might come from anyone, but then they will spread from group to group so everyone is working off the same page. We will help each of the pioneer sites make sure that all the right people are involved, so we can get things moving as soon and as smoothly as possible.
They will address problems of scale, harnessing patient power, prevention, improving public health, collaboration with other sectors, and working with mental health groups.
All the sites will have in common ambition, dedication and innovative ideas. We will give them a unique package of support, information and advice so they can make the most of this opportunity.
Again, that won’t be prearranged. It will be based on what’s actually happening on the ground, and what they say they need. But we can say that help will come from across government and the whole range of national partners in this room and more besides - not just the Department of Health. Depending on what the pioneers ask for, it might include financial modelling, payment flexibility or help with writing new contracts.
We will be permissive as a matter of principle. If the pioneers want to try something new or work in a different way, our starting point will trying to help, rather than coming up with ways to deny them.
On top of that, we will provide each site with a dedicated ‘account manager’ – a main day-to-day point of contact help them get whatever support they need.
Each pioneer site will be selected by a panel of experts. As a demonstration of our commitment to become a global leader in integrated services, those experts will be both national and international. We need to build links with the best in the world. We should be willing to be challenged to get it right – to be the best.
Other groups, like the NHS Confederation, SOLACE and the Care Provide Alliance, are already coming forward to get involved and will help us reach the as yet untrodden pinnacle of integration.
We hope to add more waves of pioneer sites in the future, to make sure we maintain this momentum.
And they will go public about what they did, what they learn and how they succeed. Making sure that the lessons are spread around.
They will be part of a network of practitioners across the country, so the newest and most exciting practice can be shared as quickly as possible across the pioneers, as well as more widely.
We’ll link them to the Community Budgets sites, who have already taught us so much about integration.
We’ll work closely alongside every pioneer site from the start, to make sure we know exactly what the benefits are.
Using the lessons that these sites teach us, I want to make integrated health and care the norm – not just in these sites but everywhere.
Today, the partners are publishing this document [hold up] which sets out our shared commitment to breaking down the barriers to delivering person centred joined up care and support – and the steps we’ll take to support localities to do this.
And I want to make it clear that this new work is designed to help a vast range of people, including children, people with learning disabilities and people who use mental health services. We now want to see integration across a whole local system of care, not just small-scale time limited experiments.
And this is not just about freeing up hospital beds, although that will be part of it. Any one of us might need support from several parts of the health and care system, not to mention other services. And we all want our care to be properly joined up so we can concentrate on getting on with our lives, not wasting time acting as a go-between between different parts of the health and care system.
By the end of this year, we will have a new measure of people’s experiences – so we can see whether people with all sorts of different needs are actually seeing those changes.
NHS England have worked with National Voices and other big players in health and care, we have also managed to overcome a major stumbling block to integration – we have come up with a proper explanation of what integration actually means for our day-to-day work.
It is something that everyone will be able to look and say, ‘This is the type of thing we want to aim for.’
It doesn’t make sweeping claims about what everyone has to do. It isn’t prescriptive. But it does provide a guide to the sort of things that integrated care will achieve. Things like better planning, more involvement for service users, and free access to more shared information.
It is written not just for the experts, but for patients, people, families and carers. It reflects what is important to them and shows them in black and white what they have a right to expect, so they can then demand the most helpful care and support.
Ladies and gentleman, today we are faced with a crossroads.
One road is well lit. It is the status quo. In many ways, it is an easy one to tread – it is familiar, we know all about it. But it leads to a precipice down which we will fall.
The other road is different. It is something new. To some, its newness may be a bit intimidating, even a bit scary. But it leads to a better tomorrow – a health and care system which can avoid the precipice, an NHS with a sustainable future.
The path we take will define our nation’s health for generations.
We must integrate or disintegrate.
But I am optimistic that with the new pioneer sites and the other developments announced today, we can radically improve the standards of care for millions of people, now and in the future.