Chris Ham, Chief Executive of The King's Fund, looks at what the health and social care system in England can learn from the experiences of the other countries of the United Kingdom.

1. Integrated care in
Northern Ireland,
Scotland and Wales
Chris Ham
Chief Executive, The King’s Fund

2. What was the aim of our study?
Different countries in the UK have taken different
routes to health care reform
Northern Ireland, Scotland and Wales have
adopted simpler, integrated structures than
England
Governments in these three countries have also
turned their backs on competition and
emphasised the importance of collaboration
Each country has sought to promote integrated
care in its own way
What are the lessons for England?

3. How did we carry out the work?
Experts in these three countries were
commissioned to write papers using a common
format
The papers describe the structures and policies in
place and their impact
They also present examples of innovations in
integrated care in each country
The drafts were discussed and reviewed by the
authors and staff at The King’s Fund

4. Variations on a theme
Northern Ireland has had an integrated health
and social care system since 1973 with a
commissioner/provider split
Scotland has had an integrated health care
system since 2003 without a
commissioner/provider split
Wales has emulated the experience of Scotland
since 2009
In Scotland and Wales local authorities continue
to provide social care

5. Key messages
Structural integration brings few benefits unless
accompanied by many other changes
Northern Ireland has not realised the potential
benefits of integrated health and social care
Scotland has made most progress for reasons
outlined later
Wales has only moved to an integrated health
system recently and it is too soon to make a
proper judgement

6. What factors matter other than
structural integration?
1.Coherent policies that promote and support
integrated care – including a national
performance framework and a single outcomes
framework
2.Governance arrangements that enable
different organisations (especially local authorities
and NHS bodies) to work together to develop
joint integrated care strategies

7. Lessons learned
3. Political, managerial and clinical leadership
at all levels that ensures a clear and consistent
focus on integrated care
4. Organisational stability to avoid distractions
and delays
5. Willingness to challenge and overcome
professional, cultural and behavioural
barriers to integrated care within the NHS and
between the NHS and social care

8. Lessons learned
6. Commitment to integrated care as a policy
priority for government as a whole
7. Maintaining this commitment over sufficiently
long period to enable policies to have a
measurable impact
8. Financial support and flexibilities to enable
introduction of new models of care (eg, Change
Fund in Scotland and ‘invest-to-save’ schemes in
Wales)

9. Lessons learned
9. Information sharing both within the NHS and
between health and social care
10. An ability to manage the differences and
tensions that arise when public services are
organised differently (eg, in Scotland and
Wales, there is commissioner/provider separation
in local authorities but not in NHS)

10. What are the implications for England?
The government will announce a programme of
integrated care pioneers in the autumn
It is also developing a plan for vulnerable older
people which will emphasise the need for
integrated care
The challenge will be to move towards virtual
integration in England as structural change is not
on the agenda
This could be an advantage if policy-makers are
willing to heed the lessons from elsewhere

11. Implications (2)
Policy-makers in the Department of Health and
other national bodies should study the lessons we
have identified and act on all of them
There should be a long term commitment to
integrated care across government
Policy barriers should be removed or amended
eg, perverse incentives like payment by results
Health and wellbeing boards could play an
important role
The allocation of £3.8bn in the spending review
could help to galvanise change

12. Implications (3)
Much will depend on alignment of political,
managerial and clinical leaders to bring about
change
There needs to be a strong and shared
commitment that integrated care is the right
route to take
The risk of organisations looking after their own
interests rather than working together must be
managed
Performance management and outcomes
frameworks need to be aligned

13. Finally
Integrated care is the right thing to do but it is
also hard to do
This is why successful examples are still few and
far between
A transformation is needed to develop the
services required for an ageing population and to
meet the challenge of multimorbidity
Persistence over time and committed leadership
are key ingredients