A new operating model for health and care
Objectives of the health and care system
ICSs’ four purposes
Aneurin Bevan founded the NHS in 1948 based on the principles of providing comprehensive, universal, high-quality, patient-centred, collaborative, efficient and accountable healthcare, free at the point of use. Notably, this extended to improving physical and mental health as well as preventing ill health. [20] The NHS’s raison d’etre remains broadly the same today. [21] Arguably the main change the new NHS Constitution must reflect is the move towards a social model of care delivered at a neighbourhood level.
But over subsequent decades the NHS has undergone various reforms and evolutions – with its most recent now underway. There is now a much greater acknowledgement of the inequalities that exist in society, and it has become eminently clear that the NHS is just one player in a complex ecosystem of public services that influence citizens’ health and prosperity.
The Health and Care Act 2022 introduced integrated care systems (ICSs) – through both integrated care boards (ICBs) and integrated care partnerships (ICPs) – which bring together health, care and other key organisations in a local area to plan and deliver joined-up health and care services. [22] The 2022 Act formalised the ‘triple aim’ as a guiding principle for ICS partners and a statutory duty on NHS bodies within ICSs, encouraging them to work collaboratively to deliver more joined-up and effective care, while also ensuring that resources are used efficiently. [23]
In subsequent guidance, NHS England offered a more contemporary description of the objectives of the health and care system by asking ICSs to fulfil four core purposes: [24]
- Improve healthcare and population health outcomes
- Reduce inequalities in outcomes, experience, and access
- Increase productivity and value for money
- Support social and economic development
This fourth purpose seeks to maximise the NHS’s already significant contribution to economic growth while recognising the importance of socio-economic factors in the wider determinants of health, thus helping deliver the government’s Health and Growth Missions. [25]
As constituent parts of ICSs, statutory NHS and VCSE providers and local government responsible for delivery. How each purpose is delivered should largely be left to local discretion. This is important, as local areas vary in terms of their power structures, quality of relationships and operational capabilities.
Shifting to a more preventative and empowering model of care
In the context of the government’s current priorities, there is one core, cross-cutting objective from which to hang a new system operating model.
The government has set out three clear priorities or ‘shifts’. But in the context of the operating model these can be boiled down to one: the left shift. The analogue to digital shift is a fundamental enabling function and therefore a vehicle for the wider reforms. Meanwhile, simply treating unwell patients in a community setting rather than a hospital building is unlikely to dramatically improve efficiency or outcomes – those services must be preventative in nature.
The core challenge is therefore shifting to a more preventative and empowering model of care, particularly in relation to higher intensity users, which is delivered closer to people’s homes. This is sometimes referred to as the ‘left shift’. Keeping people well will require different skills to those held exclusively within the NHS.
To deliver this objective, the system must:
- Move the money: A smaller proportion of NHS spending must go into acute hospital-based activity. This cannot be achieved by demand-side measures alone because there is little or no evidence that these can enable a reduction in acute capacity – much less generating cashable savings. Change therefore must start from an explicit commitment to reducing acute capacity – something which must come nationally and also within systems.
- Boost out-of-hospital capacity: Simultaneously, capacity needs to be built in out of hospital services – primary, community and mental health settings – so they are able to reduce demand and offer better alternative provision. This also means reengineering a hospital-focused workforce to support care in the community.
As strategic commissioners, responsibility for 1 and 2 will primarily sit with ICBs. They can achieve this by managing contracts with providers in a way that maximises the value of the available resources and improves population health. Payment reform is needed to enable ICBs invest in earlier, more cost-effective interventions.
The operating model is key to enabling the gain/loss share to align financial incentives. By focusing the entire health and care system on this single challenge, the new operating model can reduce complexity and cost. If the above actions are committed to, the decision about which organisation leads the shift should be left to local discretion, according to organisational maturity. A range of delivery models is therefore needed. This is explored further in this chapter.