Meaningful Measures of Integration for Care

Dan Wellings writing at the King’s Fund: The NHS long-term plan confirmed, once again, that collaboration is now the organising principle of the NHS, and that integrated care is the idea on which national leaders have pinned their hopes. There have been a number of initiatives to integrate services over the past decade, but the pace picked up considerably with the appointment of Simon Stevens as the Chief Executive of NHS England in 2014 and the publication of the NHS five year forward view. If anything will define his legacy when he eventually steps down, it will be the success or otherwise of this.

Up to now, efforts to measure the success of integrated care have tended to focus on whether demand for acute services is reduced as a result of integration and whether costs for acute care are reduced. The evidence for these is inconclusive but focusing on these as the desired outcomes misses the point. NHS England says that for health, care and support to be ‘integrated’, it must be person-centred, co-ordinated and tailored to the needs and preferences of the individual, their carer and family. So, who is best placed to tell us whether integration is working? It is users themselves. What impact does integration have on users’ experience of services? Is their quality of life improved? The problem is we don’t have the right measures in place to answer these questions. This is a significant gap.



The health and social care system has an extensive survey programme, measuring people’s experiences of a range of services from the GP patient survey and the inpatient survey to the adult social care survey. The programme hears from over 1 million people a year, but while they measure experiences of individual services, they provide limited understanding of how well (or otherwise) these services are working together. Given we know that many of the problems people face are because services are not always joined up, we need to come up with new ways of measuring and collecting this type of data. If the system is transforming, then so should the ways we measure it.

This issue is recognised in the NHS long-term plan which outlines the need for a new ‘Integration index’, the aim of which is to ‘measure from patients’, carers’ and the public’s point of view, the extent to which the local health service and its partners are genuinely providing joined up, personalised and anticipatory care.’ It seems there is a real opportunity to put this right.

With this in mind, The King’s Fund, together with Kaleidoscope, held a workshop earlier this year bringing together a group of people to come up with potential solutions to this problem. It certainly felt like we had the right people in the room; representatives of national bodies, patient groups, academics, survey experts and people from local systems (both local government and NHS). As I was sending out invites, it became clear to me not only how many people were working on aspects of this question, but also how long people had been trying to come up with ways of doing this, myself included.

Several potential solutions were developed, tested, challenged and refined. There were a few ideas that might just work with the right backing and further testing. There will be pitfalls and barriers on the way; those of us who have worked on this agenda for some time are under no illusions about how challenging this will be to get right. The danger of this type of work is that it looks far easier at first glance than it is. To produce measures that are valid and reliable, allowing us to understand both variation across areas and between different patient groups, is no mean feat. There are lots of technical questions that need answering, including how to achieve the right sample – but the solutions developed in the workshop were promising, as was the consensus around them. There was a real optimism that this can be done with the right backing.

The participants were then asked to come up with reasons why the development of a new measure might not succeed, and the number one reason cited was that there would no ownership of the need to find a solution. It can be done, but it will not be easy and will need support from the very top of the NHS and local government to overcome the inevitable challenges. Too many efforts in the past have not had the necessary backing from those in the right places.

It needs to be done correctly, providing robust data that is fit for purpose. There is science behind these surveys in the way they are sampled, the way the data is analysed and how the results are interpreted. What is measured should start with what matters to people and it must be user led, but there should also be expertise in how the collection is designed.

Importantly, this work will require investment and time to understand the feasibility of the ideas developed in the workshop. There is a real risk here that something will be developed quickly that does not work. This is too important to get wrong. If done right it will be a significant achievement. If not, as Richard Taunt from Kaleidoscope said, we could be sitting in the same workshops in ten years’ time, still asking whether integration ‘works’ and still wondering why not enough has been done to put the right measures in place to find out.



Hospital bed numbers – can the downward trend continue?

Since sustainability and transformation partnerships (STPs) published their plans late last year, the issue of the number of NHS hospital beds has been rising up the health care agenda. Alongside integrating health and social care and boosting primary and community services, some STPs – for example Dorset, Derbyshire and some STPs in London – have included proposals to reduce the number of hospital beds in their plans.

Subsequently, some stakeholder groups have voiced concern: for example, the Royal College of Emergency Medicine thinks that the NHS needs more beds, not fewer, if it is to meet performance targets. So we decided to look into the number of hospital beds, explore trends and ask if it’s realistic to reduce numbers further in the coming years.

Hospital Beds

The NHS has been reducing the number of beds for decades: since 1987/8, the total number has more than halved from around 299,000 to 142,000. Within that, the numbers of beds for people with learning disabilities and mental health problems have fallen more substantially – by 96 and 72 per cent respectively. Several changes in the way that care is provided have made these reductions possible. For example, care for people with mental health problems and learning disabilities has gradually shifted from institutional settings into the community; technical improvements in surgery have meant more patients undergo day surgery – in cataract surgery almost all operations are now day cases; and average length of stay for hospital patients has fallen from eight to five days over the past 15 years thanks to developments in clinical practice and how patients are managed.

But can this downward trend in number of beds continue?

On the one hand, there are clearly opportunities to use hospital beds more productively. As the Getting It Right First Time initiative has highlighted, there are substantial variations in average length of stay for some procedures across different hospitals. Variations in how complex older patients are managed means these patients spend more days in hospital in some areas of the country than in others. And many patients experience delays in the discharge process meaning they spend time in hospital when they are no longer benefiting from being there. In July this year, more than 5,860 beds were occupied by patients whose discharge was delayed. Progress in these areas would help to make more productive use of existing hospital beds. While national NHS leaders are keen to make such progress, it is unlikely to be straightforward, as recent tensions between NHS England and local government over efforts to cut delayed transfers of care exemplify.

On the other hand, however, today there are a number of factors that make the wisdom of reducing the number of hospital beds far more uncertain than it may have been in the past. England’s population is growing and ageing: by 2030 one in five people in England will be aged over 65, and therefore more likely to need health care. Demand for hospital care is rising with increases in A&E attendances, emergency admissions, and elective admissions. In turn, bed-occupancy levels in hospitals have risen to new highs in the past few years; in 2016/17 overnight general and acute bed occupancy averaged 90.3 per cent. Reductions in average length of stay have slowed in recent years, and may well slow further in the years ahead. Out-of-hospital services – particularly intermediate care and social care – which play a key role in supporting people as they leave hospital are under real strain with access to publicly funded social care becoming more difficult. Finally, the simple fact that the vast majority of beds for those with mental health problems or learning disabilities and beds for the long-term care of older people have already been closed means there is very little scope to reduce numbers further. Instead, future reductions in the number of hospital beds would mean reducing the number of acute beds, which historically has been more difficult. These factors help to explain why the pace of reduction in the total number of hospital beds has slowed in recent years – falling only around 4 per cent between 2012/13 and 2016/17 – and why bed-occupancy levels have risen.

The NHS’s record over the past 30 years is one of success. Adopting new ways of providing care has allowed the service to provide higher-quality care to increasing numbers of patients while reducing the number of hospital beds. But it doesn’t follow that the number of beds can be reduced indefinitely. Today circumstances make it less clear how patient needs are going to be met effectively if more beds are closed – particularly in light of the lack of money to develop alternative out-of-hospital services. So, while some areas may be able to safely reduce the number of beds, substantial reductions in the total number of NHS hospital beds in the next few years seem neither achievable or desirable.

Source: Leo-Ewbank at the King’s Fund