Integrating health and social care: a path to better services and outcomes

Natasha Mutebi; Thomas Powell

Overview

Health services and adult social care services in the UK have traditionally been funded, administered and accessed separately. While healthcare is provided by the NHS, social care has largely been the responsibility of local authorities.

Health and social care in the UK is devolved but all nations of the UK have sought to improve joint working between health and social care services.[1] This article broadly focuses on England, with reference to the devolved nations where relevant.

Better integration between health and social care in England has been proposed to:

improve outcomes in population health and healthcare
tackle inequalities in outcomes, experience and access
enhance productivity and value for money
help the NHS support broader social and economic development[2]

Greater collaboration across services is also widely seen as being central to meeting the challenges of rising demand from an ageing population with increasingly complex needs (PN532, HS71).[3]

Integration is a broad term and definitions vary. Recent policies in England that have encouraged greater integration between health and social care define it as care that is person-centred and coordinated across care settings.[4]

As well as improving the outcomes and care experience of service users, some evidence suggests that care integration can improve population health and reduce health disparities.[5]

Though the evidence-base on the cost-effectiveness of integration is limited, it has also been suggested that integration could save money by reducing emergency hospital admissions or by transitioning to community-based health and social care hubs.[6] Integration may also prevent delays in hospital discharges, particularly when service users with ongoing care needs can be supported to leave hospital when they are medically fit enough to do so.[7]

However, assessing and measuring the effectiveness of integration efforts and policies can be difficult.

Challenges and opportunities

The UK’s is experiencing increased demand for NHS and social care services, and the financial and workforce pressures that result from this.[8] An increasing number of people are living longer with multiple long term health conditions and complex needs, and require support from a wide range of services at home, in the community and in hospitals. The Health Foundation has projected that the number of people living with major illnesses in England is projected to increase by 37% by 2040, from 6.7 million (2023) to 9.1 million.[9]

The Better Care Fund was established in 2015, requiring the NHS, government departments and local authorities in England to agree on joint spending plans for integrated health and social care.[10] In June 2022, 42 Integrated Care Systems (ICS) were formally established across England, bringing together health and social care providers.

The Department of Health and Social Care has proposed that integration of health and social care should also result from collaboration across smaller geographies within ICS, called “places”.[11] Place-based partnerships often, though not always, match the area covered by a local authority.[12]

Some stakeholders highlighted the challenges facing the recently formed ICS. In 2022 the head of the NAO said that the ICS model of integrating health and social care services “is being implemented with broad support, but at a time of extreme pressure on both services.”[13] The NAO also highlighted that incentives for ICS were often focused on short term improvements, like elective care recovery, rather than on strategic change.[19]

Despite political and public support for moving more care away from hospitals,[14] recent governments (2018-2024) have allocated substantially higher funding increases for hospitals than for community and primary care services.[15] The Darzi report in September 2023 highlighted that ICS leaders are also held back by a lack of investment in capital and social care services.[16]

The House of Commons Health and Social Care Committee Inquiry Report in March 2023 noted that it is unclear what specific benefits will be achieved within the broad objectives of ICS, and how progress will be measured.[17]

The report of the Hewitt review of ICS accountability was published in April 2023. The review identified six principles necessary to ensure ICS achieve their potential:

collaboration within and between systems and national bodies
a limited number of shared priorities
allowing local leaders the space and time to lead
providing systems with the right support
balancing freedom with accountability
enabling access to timely, transparent and high quality data[18]

The government published a joint response to the Hewitt Review and the Health and Social Care Committee report on ICSs in England in June 2023. The response welcomed the wide engagement carried out by the Committee and the Hewitt review and recognised the importance and potential of ICS.[19]

NHS England’s 2023 ‘Delivery plan for recovering urgent and emergency care services’ included commitments to improve discharge processes between hospitals and other care providers. NHS England said increased capacity in social care and intermediate care (where the NHS funds temporary support, such as physiotherapy services) was needed to improve the discharge process. [20] The plan stated that this “requires sustained long-term investment” in the social care workforce.[21]

The government’s 2023 social care reform policy paper, Next steps to put people at the heart of care, highlighted plans to increase the use of digital care records, suggesting this could improve the transition of service users to and from NHS hospitals and social care settings in England .[21]

Uncertainties and unknowns

While there is consensus that collaboration between health and care organisations should continue, there is mixed evidence for impact of integration on efficiency or health improvements.[22]

Systematic reviews and evidence of models in the UK and other countries have found that integrated care may enhance service user satisfaction, increase perceived quality of care, and enable access to services. Evidence for other outcomes, such as service costs, remains unclear. There is also evidence that integrated care may reduce hospital admission rates and lengths of hospital stays, although more research is needed to establish the effect of integrated care on these patient-related outcomes.[23]

Despite some reviews taking place during a period when services have struggled to cope with increasing demand, there were some indications that integrated care models improved service user access to services.[24]

In February 2023, the Health Service Journal reported that efforts to improve integration of health and social care in England had not delivered an overall reduction in delayed discharges.[25] The Department of Health and Social Care has since reported evidence that a decrease in delayed discharges was associated with additional funding distributed through the Better Care Fund between December 2022 and January 2023.[26]

There are challenges and uncertainties to developing a robust evidence base to show that specific integration measures improve outcomes as it is difficult to isolate the impacts of integration from other factors. The wide range of potential objectives for integrated care, and the variety of measures that can be used to evaluate outcomes, also make comparisons between different schemes difficult.[27]

National Audit Office (NAO) reports in 2017 and 2020 highlighted the limited evidence base regarding value for money and efficiency benefits of health and social care integration in England. The NAO noted that data to assess outcomes and experiences are not consistently collected across different settings.[28]^,[29]

In 2021 the Nuffield Trust considered the different paths toward health and care integration taken across different parts of the UK, drawing insights and learning from how different policy approaches may have contributed to different outcomes for their communities. The report found that robust evidence for the impact of integration policy remains limited in all parts of the UK.[30]

Key questions for Parliament

How should the success of integrated care systems in England be assessed?
What is the evidence for the impact on outcomes and value for money with integrated care policies?
What further research and metrics are needed to assess whether integrated care policies are achieving their aims, and if not, how they can?
Can the benefits of integration policies in the UK be realised in the context of unprecedented demand and financial pressure on the NHS, local government and social care providers?
What lessons can England learn from the way health and social care services work together in the different nations of the UK and in other countries?