Integrated care - The next step in Norfolk and Waveney’s NHS overhaul

Picture: Ian Burt

Picture: Ian Burt - Credit: IAN BURT

Norfolk and Waveney's NHS is changing - and not for the first time - as it bids to move towards a more integrated system of care. Health correspondent Geraldine Scott explains what the new system is, and the impact on our health service.

The county health service faced its biggest shake up in a generation back in 2016 when it was announced that without change Norfolk and Waveney would face a £545m deficit by 2021.

This prompted the creation of the sustainability and transformation plan (later changed to sustainability and transformation partnership) to bring together all players to look at future ways of working and how the system would survive.

Now Norfolk and Waveney STP has submittted a bid to become a integrated care system, known as another three-letter acronym, the ICS, in the second wave of systems of the kind being introduced.

What is the challenge?

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Rising demand, an elderly population, and financial constraints have put the NHS under enormous pressure. In this region between 2016 and 2021 it was expected 40,000 more homes were to be built, there would be 9,000 more people with diabetes, 5,000 more people would have strokes, 12,000 more would be diagnosed with coronary heart disease, and 7,000 people would have dementia.

STPs were created across the country in 44 areas (known as footprints) to tackle this and move away from the hospital-based care and provide more help in people's homes or the community, while breaking down barriers between services.

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In practice, this means in Norfolk and Waveney preventing 17,000 A&E admissions and making savings of millions of pounds.

Why the change to an integrated care system?

Since the Health and Social Care Act 2012, partnership working in the NHS has not been easy, as the legislation was designed to promote competition.

But in 2014 the NHS five year forward view - a document setting out ambitions for the health service - recognised the need for closer working.

According to respected thinktank The King's Fund ICSs are the next step along from STPs and they 'take the lead in planning and commissioning care for their populations and providing system leadership'.

An ICS has more control over funding - and may take responsibility for a whole system 'control total' - and can also create collective decision-making structures.

Is this good for Norfolk and Waveney?

In documents which have been put before councillors in recent months, the benefits were said to be:

• Enabling the STP to make better use of the £2.6bn health and care resources;

• Increasing the integration of services, including commissioning;

• Enable a whole system approach to supporting challenged services;

• Working more closely as regulators, commissioners, and providers;

• Support the integration between acute services;

• Make Norfolk and Waveney a more attractive place to work;

• Enable a fundamental shift in culture across services.

One criticism of the systems are they do not have legislative underpinning - they are run on good will and voluntary participation - but so far all the organisations in Norfolk and Waveney are in.

And ICSs initially came under scrutiny for their original name - accountable care organisations.

They were rebranded over sensitivities about the name which was coined in the US and but campaigners' fears they were Trojan horses for privatisation have continued.

A group including the late Professor Stephen Hawking, who died last month, were granted permission to bring a judicial review against NHS England and health secretary Jeremy Hunt over the changes.

Locally Jan McLachlan, Sue Vaughan and Jan Ainsley - from the NHS NAG - said: 'The creeping privatisation agenda has been operating very stealthily [...] this is because if the public really knew how far down the line NHS privatisation really was there would be a massive outcry.'

But a spokesman for the STP said the Norfolk system would 'bear no relation to American models of care'.

And the Department for Health and Social Care have previously strongly rejected such claims. It said it was 'misleading' and 'irresponsible scaremongering' to suggest the systems were being used to support privatisation of the NHS.

Nigel Edwards, chief executive of the Nuffield Trust, told the Financial Times this month that fear over privatisation 'has a major drawback to it, which is at the moment there's nothing to privatise'.

Because ICSs are purely voluntary, he told the newspaper 'you can't privatise something that doesn't actually exist in law'.

Locally one key concerns seems to be over finances, with the local authority keen not to take on the financial baggage of the NHS, much of which is in deficit.

Documents outlining the ICS bid said: 'A key consideration of [Norfolk County Council] will remain to ensure that the financial liabilities of the NHS do not pass to the local authority under these arrangements.'

Does it work?

Early evidence is showing some progress is being made in stemming the demand for hospital care, but it is widely accepted that it will be many years before the real impact of changes take effect.

What happens next?

NHS England had discussions with several areas - including Norfolk and Waveney - last year about becoming second-wave ICSs, and the new cohort was expected to be announced early this year.

Leaders were not given a revised timetable, but the Health Service Journal reported some were told to expect an announcement in April or May.

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