17
Examination of witnesses
Professor David Peiris, Dr Dheepa Rajan and Dr Toni Dedeu.
Q206 The Chair: Good afternoon and welcome to the Integration of Primary and Community Care Committee. We are delighted to have international witnesses with us today. As you all know, the panel will take it in turns to ask them questions. One of our members is online and a couple will join us shortly.
I welcome Dr Toni Dedeu, senior adviser at the World Health Organization European Centre for Primary Health Care; Dr Dheepa Rajan, health system specialist at the European Observatory on Health Systems and Policies; and Professor David Peiris, chief scientist and director of the global primary health care programme at the George Institute for Global Health. We are delighted that you are able to join us; I am sure that we will receive some very useful information from you.
I will just say a word about housekeeping. The House of Lords expects to vote on various issues this afternoon. There is one large subject first, which I understand will not be voted on, but when the next business starts there will be quite a lot of votes. You will not be able to miss them, because you will hear a very loud bell and we will have to suspend proceedings for a while. I hope that will not happen during our session.
Let us get straight down to work. I will start with Professor Peiris, just because we have to start somewhere. How many countries have had marked success in integrating their primary and community care services? How did they do it, and how did we get a measure of that success and see how it worked?
Professor David Peiris: Thank you very much for the opportunity to speak at this hearing. Forgive me in advance: it is midnight here in Sydney, so I am sure you will understand if I am not firing on all cylinders.
The question of how success is defined is really interesting. With a lot of integrated care efforts, success is particularly often motivated by looking at efficiency in health system delivery, cost improvements and quality of care. Increasingly, there is also a focus on patient and provider experience and, particularly with the NHS now focused on integrating health and social care, there is also an increased emphasis on equity of outcomes.
Success can be multidimensional and different for different stakeholders. When we looked at a review of the evidence of integrated care organisations—it is a few years old now—we found pockets of evidence of success on those dimensions across the world. The literature is very much dominated by North America, Europe and the UK, with some examples in Asia and here in Australia and New Zealand as well.
Certainly, out of all those outcomes there is evidence of success, particularly in the experience of care. Providers and users of health services see this as a good thing. Cost is a bit more debatable, and the evidence is more mixed. Previous witnesses in this hearing have commented on the evidence base being variable. It can vary quite a bit, from no improvements in expenditure outcomes at all through to reductions of as much as 10% in overall health system expenditure.
However, the challenge is looking at scalable strategies. There are many examples of isolated studies and projects that have shown benefits, but how many have we seen at a much larger system level that have been able to generate those kinds of successes? There, the outcomes are much more variable. Perhaps there is a little evidence from the United States about accountable care organisations that have achieved some improvements over the last few years.
One factor for success that we know about is longevity—the longer people stay in these programmes, the more likely they are to generate improvements in outcomes. Another is having a fairly strong funding stimulus up front to overcome system inertia and the status quo of the usual way of doing things. A third factor is trying to get both the financial and non-financial incentives right to engage what is often a multidisciplinary group of providers. The fourth piece is very much community engagement. Some models that take a front-line, ground-up approach manage to achieve integration by having strong citizen engagement and participation in the governance and delivery of these care models.
Dr Dheepa Rajan: I echo what David just said about outcomes. It is definitely not easy to measure them, because integrated care is one piece of a larger puzzle in the health system. Later on, we measure things such as equity, efficiency and quality of care. Usually, a lot of interventions and measures go into improvements, so it is hard to isolate it to that integrated care piece and find a causal relationship.
Thinking about cost, the results are mixed. We might have overall increases in cost, but we should think not just of cost reductions but of increases and improvements in efficiency, which is about getting more bang for your buck—spending the same amount of money but getting better health outcomes for that same amount of money, or potentially even having slightly reduced costs while keeping the level of health outcomes and results that we have had in the past.
If we look at it that way, integrated care is definitely a good investment. That is what we see in most studies if we do not focus solely on cost but think about efficiency.
You asked about countries that have had marked success. I can give two examples, or maybe just one if we have less time. One, which has been evaluated quite a bit, is an example of an integrated care programme that has gone the whole way and has been in place for many years. It is the Healthy Kinzigtal programme in south-west Germany, which many of you have probably heard about; it is widely documented. It has all the key elements that you would like to see in an integrated care programme, bringing together primary care and community care. There is a strong element of community engagement and patient-focused shared decision-making. I am sure you have heard about all these issues in past hearings.
Maybe one unique feature of the programme is the financing mechanism, which involves insurers getting together and working with the network of general practitioners, specialists and the regional health management company. The shared savings through integration are what provide the financial incentive across the board. It has been in place since 2005. It has been evaluated several times over different programmes, and there are really positive impacts on health outcomes and especially on patient experience. There are also overall reduced costs, of course, because that is one of the main objectives of the programme.
The Chair: That sounds like a very interesting example for our work. We certainly want to know more about that. Thank you. We come to Dr Dedeu.
Dr Toni Dedeu: Thank you very much. Greetings from Almaty in Kazakhstan, where I am speaking from today. I will add to what my colleagues said. I had the privilege to be part of some initiatives and projects that tried to find other dimensions that matter in the success of the implementation of the integration of primary healthcare and community care, and even beyond community care.
In addition to the financial successes that we could mention, one issue is the level of maturity. Where do you start on that? One European project tried to define a matrix whereby you could find dimensions that could give you an idea of the level of maturity of your system. You could then compare your system with other jurisdictions’. I say “jurisdictions”, because this is not limited to the national level or to subnational levels—a region, a Land or a county; it is also possible to do with companies such as Gesundes Kinzigtal, which Dr Rajan mentioned.
One issue is the breadth of ambition. This links to the political side. How ambitious is an organisation or system in trying to bring a focus on community care to primary healthcare? Another issue, which is very relevant for evaluation, is what information systems and data you collect in order to be able to process, analyse and generate evidence. Another issue—I will just mention a few—is the workforce development. This is the key point, so I will give some examples of it later.
The final issue is the alignment of interests between health and social care. One challenge we have encountered is when two cultures are in the same basket. As Professor Peiris said, the longer an initiative takes, the better, because then the cultures can get together. It takes time to know each other.
I have some good examples. I will not say that there are gold standards—there are no gold standards in the integration of primary healthcare and community care—but some examples have generated good health outcomes, in addition to an increase in patient satisfaction and some savings or, in some cases, revenue of investment. There are a few countries in Europe where there is evidence of that. One good example is Spain, specifically in some autonomous communities there. Another is Finland, specifically in the region near the south-east of Sweden.
The region of Flanders is worth looking at, because they started to reform primary healthcare with a community orientation in 2014, so it is very new and the evidence they have generated is recent, but the mission of the politicians there means that they have a say and they work in a very top-level way. We should establish that, because other countries have done it. Outside our continent, Canada has good examples, especially in two provinces: Ontario and Quebec. They have different modes, but both are worth looking at.
I will just mention two things in this regard. One is that the success of some countries happened because there was hard legislation. In the case of Spain, the 1986 health Act made primary healthcare the pillar at the centre. The legislation followed the Alma-Ata declaration in thinking that primary healthcare should have a community-care approach to reach the entire population, not only individuals. From there, they developed a whole system whereby primary healthcare and community care are the cornerstone of their model, to the extent that the speciality of family medicine in Spain is called family and community medicine. Now, the specialised nurses are similarly called family and community nurses. That is one example to highlight the importance of hard law in this case. The same happened in Flanders at a different level, but I will stop there to allow my colleagues to proceed.
The Chair: We must move on to other questions. We will hear many more examples and opinions from you. Lady Finlay will take Lord Kakkar’s question.
Q207 Baroness Finlay of Llandaff: Thank you. Dr Rajan, you have given us examples of successes, and it would be helpful if you could send us the additional example that you were going to give us. Are there projects that have failed to demonstrate impact? Have projects failed but are just not known about because people only publish positive results and are hesitant to publish negative results? If they have failed, why?
Dr Dheepa Rajan: For the most part, it is true: we all tend to publish success stories. However, some of the not-so-successful stories are often publicised in other ways, or you get the information and documentation through other initiatives that try to learn from those failures, so to speak.
The example I would like to bring, although I would not call it an entire failure, is of 1940s South Africa, where a community-oriented primary care programme was launched as a response to limited access to care in rural areas. It looked at that nexus of primary and community care and the integration of the two to address social conditions and determinants of health, to incorporate community empowerment and participation in service delivery, and to build evidence-informed service provision.
It had a promising start. The term “community-oriented primary care” has taken off in other countries, ironically. An institute for family and community health was even launched at the time. However, later, because of segregationist apartheid politics, et cetera, this fell into disfavour. You might say that an apartheid regime is unique and does not pertain to us, but behind that lies the fact that there were interests that did not favour a focus on the health of the masses. The other interest—focusing on the health of an elite and of specific groups in society—is present in every country. In South Africa, it played out in apartheid at the time, but what was behind it is common across countries.
To cut a long story short, the leadership did not make enough effort to bring medical and health professionals on board and convince them of this. Consequently, and unfortunately, a lot of the centres were closed and converted into out-patient clinics and segregated health services. However, the idea still somehow lingered and stayed, leading for example to a new category of PHC nurses. Post-apartheid plans for the new health system in South Africa drew a lot of inspiration from that, as did the World Health Organization in its declarations on primary healthcare of Alma-Ata and Astana.
When we look at why this did not work out as well as it could have—they are now trying to revived it in many ways in South Africa—we see that it was an amalgam of factors: stakeholders were not brought on board early enough, health professionals were not brought on board and their incentive package and motivations were not thought through, and community involvement was not done early enough to gain traction.
You need a combination of early community involvement, engagement with other stakeholders, especially those without whom you cannot implement some of these policies, which is basically the health professional community, and aligned funding—funding that aligns with the needs and working conditions of health professionals alongside funding to support community engagement. This learning holds even today for any country aiming to integrate primary and community care.
Baroness Finlay of Llandaff: Thank you. We turn very briefly—really very briefly—to the other two respondents. I just wonder if you have examples of why things have failed, and perhaps of why Cuba, and Kerala in India, can be deemed to be community successes in terms of outcomes in some ways, while other places have failed.
Professor David Peiris: I am probably not as well equipped to comment on Cuba and Canada, but I will speak about one example here in Australia: a federal government policy to implement so-called patient-centred medical homes in general practice in Australia nationally. As you will all know, this is a model for integrating service delivery functions, driven by primary care and particularly GPs, to identify the holistic needs for a defined patient population but with a particular focus on chronic and complex care needs and on identifying in community services and in the hospital sector what kind of services that population requires.
The Government put a substantial amount of funding into the model, and they had a real challenge with uptake from general practices—its acceptability was questioned. One year into the model, only around 50% of the original 280-odd practices that signed up were still participating. Then, when it came to outcome evaluation, there were some improvements in the experience of care and some care processes but really not much difference in terms of clinical outcomes, and certainly no benefits in terms of improvements in emergency department presentations or hospital admissions.
It is an interesting example; it was implemented at scale but it did not achieve its intended outcomes, and there is a very large report that unpacks what went into causing that sort of outcome. Fundamentally, there were a couple of big drivers. The first, to come back to the incentives, is that GPs—I myself am a practising GP—found it hard to transition to playing this integrator role for a small proportion of their patient population when alongside that they were delivering status-quo, and in Australia predominantly fee-for-service, models of care for the rest of their patient population. Therefore, transforming practice was quite a challenging thing for GPs to do, and the business models that required changing were challenging.
There were IT incentives, risk stratification tools, and incentives to try to use our national shared electronic health record to promote cohesiveness of care, but, again, the change management required to shift general practices was variable. Some are very good at this and will always be very good at it, while others need substantial support to be able to make those transitions. That uptake ended up with a highly variable use of these tools and services to better identify the needs of the population.
So there are a lot of lessons for us in how this model did not work, but again, hardly any integrated care projects do not yield enormous knowledge and policy-relevant findings to inform future iterations in order to improve things.
Baroness Finlay of Llandaff: All those examples are very useful. Dr Dedeu, very briefly, do you have any additional insights to add about where places have failed and why they have failed?
Dr Toni Dedeu: I will mention one example, in Ontario in Canada. In 2007, it launched 14 local health integration networks, and one of the things it tried to do, with a very large and broad scope of services, including community care—so not just acute care but primary health care competences—was to engage with the community. They found that some of the services that were related to healthcare were free for the population to access. On the other hand, when they had to relate to some services that should be provided in the community and which had some component of social care, there was a fee for the service or some co-payments. So the alignment of the two models clashed. There was a review of the model and what happened at the end, and there is currently another review, but, in practice, these different sectors, which worked together, remained siloed, working separately and not integrated. In brief, that is the Ontario example.
The Chair: Thank you very much. I am sorry that we are always short of time in these committees. That is why we ask you for brief and focused answers, not because we do not want to hear everything that you want to tell us but because we have to work to a strict timetable.
On the next question, which my colleague will ask, we ask you not to spare our blushes. We have a lot of information, some of it published this morning, about how the NHS compares with other health systems. Again, I ask you for quite focused answers.
Q208 Baroness Osamor: How well does the NHS perform compared to the health services in other countries? To what extent could further healthcare integration improve this?
Professor David Peiris: It is a high-performing health system. For all its challenges and all the things that you might be critical of, it remains a well-resourced and high-performing system. It is always fascinating for me, when I compare it to, say, Australia and other OECD countries with similar levels of expenditure on healthcare, to see how differently we organise our healthcare systems and yet how broadly similar our outcomes are. It underscores how challenging this issue of integration is. It is a complex challenge, and many countries are having a go at that and trying reform, against a historical background of often very entrenched ways of doing things, and we are all tackling them slightly differently.
There are many admirable things about the NHS. I mentioned earlier the emphasis on the integration of health and social care. Compared to Australia, you are far more advanced in thinking about that. We are not even close to thinking about some of the complexities of social care services and the voluntary sector. You are much more at the cutting edge in thinking that through.
I am always envious of the much less complex payer system in the NHS. We have a very fragmented multi-payer model in Australia with federal state government silos, which drives a lot of fragmentation in the system. The NHS’s ability to use commissioning in a very cohesive way is another strength there. However, these are complex challenges and they do not necessarily easily deliver the outcomes that we desire, and I think we are all in this together in trying to understand how to achieve solutions to this.
Dr Dheepa Rajan: To echo Professor Peiris, yours is a well-resourced, high-performing health system.
On room for improvement, against other comparable high-income countries you definitely stand out on life expectancy. Life expectancy has been stalling over the last few years, and probably a lot of this is driven by the high levels of inequality that you have. That is across Europe, and one of the areas of weakness that one can see in the UK health system.
This relatively new initiative, with the integrated care systems and the integrated care boards to bring in community care with primary care, the fact that this committee even exists, and the strong emphasis on bringing in community groups and civil society into those boards, is a move in the right direction to address some of those inequalities.
Yet one also has to note, as we have in many analyses here at the observatory, that workforce planning has not been as strong as it could be in the UK. We have seen larger increases in the hospital workforce compared with the community workforce, despite a policy agenda to provide care closer to people, communities and people’s homes. Historically, and this is the case throughout most OECD countries, public health has struggled to get resources to front-line and mainstream health services.
So if you want to address those inequalities, the emphasis moving forward has to be on the community care part of primary and community care integration and on public health services over curative care services, because that is where you can really address determinants of health and issues that are being driven by inequalities.
Dr Toni Dedeu: The UK, compared with the eurozone, which includes Norway, Switzerland, Iceland, and even Israel, is average. It is not at the top and not what we would wish. I am not native to the UK, but I am resident in it, so I know the NHS as an end-user. One thing I can compare with other countries I have lived and worked in is that the training of family doctors lacks a community medicine or community care approach. Maybe this should be introduced to the curriculum or to post-education or continuous medical education.
In many countries, the community end of primary care is embedded in the training of family doctors and nurses. When I am in the UK, I see that family doctors and nurses are too clinical. They may take a holistic approach to the person, but they do not take that step forward. Another thing is that district nurses are not integrated in surgeries or practices. One challenge that at least NHS England has is that primary healthcare providers compete in the same catchment area, an approach that does not contribute to co-ordinated community interventions. That is another thing that I can see as an outsider.
Finally, there are non-direct payment mechanisms that could incentivise co-ordination and actions in community care.
The Chair: There will be opportunities to expand on that in response to the next question from Baroness Redfern.
Q209 Baroness Redfern: I think you have partly answered my question—thank you very much—but I will delve into this a little. What can be done immediately to integrate primary and community care, and is there a culture of resistance?
Professor David Peiris: That is an interesting question. Following Dr Dedeu’s comments and from listening to some of the previous hearings with other witnesses, there is an interesting challenge with GP-centric models of care. When we are thinking about the integration with community care, we are asking for a shift in how we perceive primary care. I am a GP myself, but possibly having the GP at the centre of the approach is not necessarily the only way to do this. There was an interesting discussion in a previous hearing about the gatekeeper role of the GP. The shift globally is much more towards primary care teams and team-based approaches, and thinking about the relative contributions and skill sets of a much more diffuse workforce who may not be trained in a biomedical model of care. There are some strengths and weaknesses there and some ground that may need to be ceded from our traditional models. That, to me, is at the core of this challenge of integrating primary and community care.
Another thing that is interesting to me is the size of integrated care systems. Correct me if I am wrong, but the target populations are quite large—in the hundreds of thousands to millions of people. Again, I listened with interest to a previous hearing and Professor Checkland speaking about primary care networks, which have a much smaller focus population—more in the tens of thousands of people. There is something very interesting in the challenges of delivering system change at scale but being very responsive locally. When you get to those sorts of big numbers, the evidence shows that it is harder to achieve integration at the front line.
There are some areas of work there, and not just in the UK; we are very much facing those challenges here in Australia as well.
Dr Toni Dedeu: Dr Peiris has said the magic words—multidisciplinary teams. There is evidence from countries where primary healthcare works with multidisciplinary teams. What do I mean by that? They have a team culture in which they work together and share information. Even the information system shares information. They take decisions and share decisions; it is not just the GP but the nurse, the nutritionist and the psychologist. In some countries, one success factor is bringing the social worker within the team as a link with the community to understand the real needs from the social needs of the community. It has been shown that in countries that have introduced social workers or similar professionals, they contribute to the teamwork and understanding of the needs of the population.
Just so you know, in a month’s time our centre will publish a review of a policy paper on primary healthcare networks, which are one of the concepts that we are discussing. You will have the opportunity to have that evidence. The WHO is producing this document and we are working on it. Today, it had almost its last revision, and it is good news to have evidence and documents that support these ideas.
Dr Dheepa Rajan: I definitely think that multidisciplinary teams are the direction we are going in integrating primary and community care. There is the range of skills, and then there is learning how to work and collaborate with each other. At the moment, specialists, or health workers, are not trained to work collaboratively; doctors are trained separately, nurses are trained separately, et cetera. In order for multidisciplinary teams to work in the future, we need to start training our health professionals together, with joint courses, joint clinical rotations, et cetera, so that they learn in a collaborative way. Then it will be natural for them to learn, train and work together in the future.
One of the biggest challenges of multidisciplinary teams is that everyone comes from a very different paradigm. Some come more from the biomedical paradigm and others more from the social care or public healthcare paradigm. Bringing that together to make it work is a huge challenge, and it would be made much easier if we started training our health workers earlier to see all the different paradigms more holistically.
Multidisciplinary teamwork is clearly supported. I come back to the example of the Gesundes Kinzigtal, or Healthy Kinzigtal, programme in Germany, which has a really sophisticated data infrastructure. They have partnering health insurers and share timely administrative data with all the different providers to help to improve quality and care co-ordination and respond to risk factors in real time. That supports the work of a multidisciplinary team. Making that data infrastructure interoperable is a challenge in the UK at the moment, even though your data infrastructure is quite consolidated in general and on the better side compared to other systems. But there are issues with interoperability and the capacity to analyse data and use it in real time.
Professor David Peiris: If I may, I will add to Dheepa’s comments about Gesundes Kinzigtal. We invited the medical director to come to Australia to present their experience to the New South Wales Government, and one really interesting comment he made that stuck with me was around the provider network number. They tried to limit the number of providers engaged to about 100. They felt that when you go bigger than 100 providers of multidisciplinary skill sets, it gets too complex to bring people together, to build relations and to foster teamwork gathering around the data, as Dheepa mentioned. So they were very active in cultivating fairly intimate networks of providers to work on their challenges.
The Chair: Thank you very much. We will go on to Baroness Shephard. I want us to get the next three questions in, so I must appeal for focused answers from you. We could be here for several hours listening to all the interesting things you have to say, but we have to keep to our timetable.
Q210 Baroness Shephard of Northwold: My question is about outcomes of policies to promote integration. I feel that you have all touched on these matters in the answers that you have already given, so forgive me if you feel we are going over the same ground, but it is about outcome.
How do the outcomes of policies to promote integration in England compare with those in other systems with which you are familiar? You have just given an important clue on what numbers of providers might or might not succeed. There has also been a key point about the training of GPs—and about the attitudes of GPs, because they feel full-time enough without having to be the kingpin of integration, which I think resonates with all of us and we understand that.
If you can fish out from the valuable evidence you have all given so far something about a bit focused about outcomes, that would be great.
Professor David Peiris: I might be at risk of repeating myself, but we see from integration efforts and improvements, particularly in the experience of care, that patients and providers value this way of working and see its benefits. The promise of efficiency gain and savings gain is more challenging. It is a challenge for policymakers and politicians to stay the course when implementing big system reforms like this, because they are not necessarily going to see impacts in terms of budgetary improvements for some years, and that is a challenge because it goes beyond election cycles.
On the quality of care and improving integration with social services, you are very much ahead of the game in the evidence base. These 40-odd integrated care systems will generate of a lot of novel evidence that we do not yet have internationally on that issue. There is a range of benefits that we might see, but, again, I emphasise that they are long term.
Dr Dheepa Rajan: The most evidence we have on outcomes is in the user/patient satisfaction area, as well as in quality of care and the feeling that the health system is being responsive to people’s needs. In equity, we see gains in population groups that traditionally had poorer health outcomes, for example. The efficiency question is a hard one. On getting to those outcomes, one thing you could focus on in the UK at the moment because of the inequality issue that you face is to put a strong emphasis on civil society, community and public engagement.
On the community care aspect of primary care, you have traditionally focused quite a bit on the health and social care integration piece, and as Professor Peiris said, you are far ahead of many countries on that. Now is really the opportunity to link that much more closely with primary community care engagement integration. As I understand it, the plans are quite grand with integrated care systems and integrated care boards, but, as we are seeing in the literature and in our engagement with the UK, you have a lot of pockets of good practice that have not been taken to scale, so you have pockets of great practice when it comes to social prescribing—you have Manchester, which is always reported as a best practice example, but at national level all that seems to go slightly unacknowledged.
If those pockets of good practice are to be capitalised on and implemented across the board, it will require resources, of course, but mostly it will require capacity building from the national level down to local levels, because those pockets of good practice are likely to be happening in places where there is capacity and resources. So in order to make sure that other regions and other areas are able to do the same thing, some support will need to be given along with resources and capacity building to ensure that they are able to do what those other good practice areas are doing.
Dr Toni Dedeu: I turn to the UK now and will give an example of something that happened. Maybe you remember the pioneers and the vanguards that tried integrating health and social care services. An evaluation by the Nuffield Trust resulted in the development of hundreds of indicators. The only indicator that proved the success of the vanguards was the reduction in admissions to hospital via A&E of people with chronic conditions. However, even as a start, this is a success. If one dimension is positive, it is worth it, because people with societal complexities who go to hospital in an emergency are the ones who are most likely to be admitted and are a very big challenge.
Another thing that it is important to mention is patient-reported outcomes—what the patient reports as a good outcome, and their expectations. If you implement policy X, Y or Z, you expect patients’ and citizens’ experience of the health system to be better, so if we want to improve the co-ordination, integration or whatever of health and social care, we should look at the experience of the person who uses the services. That would be another indicator, as a proxy, of a good policy implemented.
Baroness Shephard of Northwold: Thank you so much for all three answers.
Q211 Baroness Tyler of Enfield: My question is about something you have all touched on, which is how you get the balance right between central diktat, or central directives, and getting more integration through localism and the work of local partners. Based on your knowledge and experience, how important is it to get that balance right in delivering fully effective integrated care, and do you have examples of countries that have succeeded in getting that balance right?
Dr Dheepa Rajan: We recently did an evidence review looking at decentralisation and at that balance. It is pretty clear that decentralisation overall, to put it simplistically, is a good thing for local health system responsiveness, but certain conditions need to be met for it to really improve local, within-region, equity, efficiency and people-centredness, and help the local population overall.
One is that, locally, health authorities and the authorities that are formally delegated to them have the power, because some of that authority is often be kept at a central level for a variety of reasons, and have the capacity to take on those delegated responsibilities. A key point is that the local authorities are able to use that authority and capacity for regular community engagement and outreach with people, including civil society. The whole point of decentralisation and the objective that is often given for such initiatives is to be closer to people and be more responsive to their needs. For that, there needs to be adequate capacity and accountability towards people’s needs, which means engagement with communities.
In that sense, if you look within the region that have been decentralised, if there is capacity and authority, we have good results in local equity, marginalised groups, efficiency, people-centredness et cetera. However, where those conditions have not been met, many of the studies show mixed outcomes.
On the balance between localism and a central steer—that is, centralisation—it is really important to keep in mind that decentralisation means that a lot is dependent on the local-level authority and capacity. This capacity can vary throughout the country, so between-region inequalities can increase with decentralisation unless you have a strong central steer to even out those differences. I mentioned earlier that there is a strong role for central government to build capacity and support regions that have less capacity, funding and access to resources; this is a clear centralised role that needs to be in place in order to bear the fruits of decentralisation at the local level. That balance definitely needs to be there.
Finally, on examples, many decentralised countries struggle with this. There are lots of examples of where it has not worked very well. In Italy, for example, there were great results at the regional level but between-region inequalities have really been exacerbated through decentralisation. One study from Canada that looked at interregional inequality basically showed that income-related inequities in healthcare use were mostly driven by differences between the provinces, not by differences in income between the different groups.
So it really is key to have that central steer, which should have as the main objective evening out the differences across the regions in order to bear the fruits of decentralisation. That is where the balance needs to lie; in practice, it will mean some adjustments and trial and error along the way.
Professor David Peiris: I would like to make one quick comment. The meso-tier—middle-tier—organisation that plays the integrative function is a source of interest to me in my research. We talked a bit earlier about what the size of that should be and what population it should be supporting. My sense is that it is too big a population for integrated care boards. The primary care networks are perhaps at a more nimble level to perform that integrative function. However, you do not want to go too much lower than that. In Australia, for example, we found with the healthcare homes model I mentioned earlier that, if you leave it to front-line general practices, it is too small to achieve integration at scale.
Dr Toni Dedeu: I had the privilege of being in Scotland when health and social care integration was going on. I lived there for three years, contributing to and assessing that integration from the University of Edinburgh. At the same time, I was in Catalonia, implementing the integration of health and social care. One thing that both regions had in common was that it was important to have clear health and social care objectives that were aligned. That is one thing. Let us think about this.
At the governmental or regional level—in this case, the country of Scotland and the region of Catalonia—it is important to have good guides to guide all the stakeholders below. One success factor is taking into account decentralisation within the region, because the context matters. At county level and sometimes at local level, this is important so that local stakeholders have a say in and know about the context.
Another thing that binds here is that it goes smoothly if there is a shared budget. On the other hand, each context can have its own priorities because it is different. A mining area—it could be in Wales—will have different population needs from those of another place. With this contextual thing, when you try to integrate primary healthcare and social care, working with the community, the context matters. As you see, it is about centralised guidance from government, either regional or national, but going from the top down matters as well. Catalonia and Scotland are success stories in primary healthcare and community care. There is evidence now that it worked and works.
The Chair: The last question comes from Lord Watts. We will have to ask for one specific answer here.
Q212 Lord Watts: I have the quick-fire question. If you could recommend one thing that the UK Government could do to better integrate health services in England, what would it be?
Professor David Peiris: Invest up front to overcome status quo inertia, go the long haul for achieving change, and rigorously evaluate all these models as they get implemented, because the knowledge generation will be enormous for not just the UK but all of us internationally.
Dr Toni Dedeu: One of the key things is good triangulation—I am introducing this word here, because in the UK it matters—between primary healthcare providers, public health and social care services. This triangulation is crucial. The alignment of objectives together is the only way to move forward in the integration of primary healthcare and community care.
Dr Dheepa Rajan: I would say two things.
The Chair: Just your most important.
Dr Dheepa Rajan: Integration is extra work for anyone. In a lot of the successful examples, we have seen investment in full-time equivalents—that is, in somebody to actually do the integration piece. You need to invest in staff to do that, at least in a transition period, which can last several years. Secondly, you have to invest in building capacity in order to do meaningful community outreach and engagement, bringing civil society not only into implementation but into decision-making. This is really the weak link in most places. In the UK, you have lots of great examples and pockets of good practice. Study them and try to expand them to the rest of the country.
The Chair: Thank you very much. I can hardly do justice to the richness and range of the answers you have given us today. As always, time is our enemy, but I thank you on behalf of the committee for your thoughts and contributions, as well as for any other examples that you may like to send us if you feel that there are things you have not had an opportunity to say; we would be delighted to receive them. Thank you again for your time. This meeting has happened at a very unsocial hour for some of you. At least we have escaped having to leave you for a vote in the House of Lords—let us be thankful for that.
