Why a one size fits all approach to ICS’s planning is unlikely to work effectively
Each Integrated Care System (ICS) has a unique set of circumstances and challenges deriving from factors such as size, relationships and social and economic environments. It is fair to say they are not yet on a level playing field in terms of development and may lack the ability to structure around and respond to local needs. A recent report by Future Health, authored by Richard Sloggett and funded by Acumentice, examines the starting position for these new organisations, stating that whilst the ICS’s face similar challenges (such as workforce pressures and a lack of capital investment), the scale of primary challenges varies.
In this blog, we discuss some of these challenges and examine the metrics used in the report to define system pressures, alongside the level of variation in deprivation and population health need.
The report research reveals that whilst ICS’s face similar challenges, the scale of their primary care challenges often varies. Data from NHS Digital for 2021 shows that an unprecedented 367m General Practice appointments took place in 2021 in England. Balanced against this, analysis of NHS Digital General Practice Workforce Statistics by the British Medical Association from September 2015 to August 2022 shows that despite 1,850 fewer fully qualified FTE GPs today than there were in September 2015, each practice has on average 2,222 more patients than in 2015.
The art of managing increased service user expectations, and rising demand against a declining workforce is influenced by many variables including each ICS’s response to the scale of challenges it faces. Variation in workforce availability is no doubt a key contributor to the range of pressures seen in the report. Having the right workforce in position and a wider range of practitioner skills will place each ICS in a better place to respond to the demand challenge.
In terms of accessing Primary Care services, one indicator used to assess this in the report is the number of GPs per head of population. The assumption being that the more patients registered to a GP, the more likely that access will be restricted. Indeed, what is considered as good access goes much further, and future operating models and design of metrics, will need to address how each health system removes barriers to healthcare constrained by the individuals social, educational, religious, cultural, language and other circumstances.
The elective backlog has grown to an unprecedented level and now stands at over 7 million patients (August 2022). Analysis of the backlog has shown that those living in the most deprived areas are twice as likely to wait more than a year for treatment compared to those living in the least deprived areas, highlighting significant variance between areas of high deprivation and affluence. Although the origins of health inequalities are complex, good data, and the analysis of it will play a key role in both identifying and reducing health inequalities as well as in tackling the elective care backlog.
To further understand relative pressure between systems from a secondary care perspective, the following three metrics were analysed:
- 4hr A&E waiting time
- % in 18 weeks wait
- % 52 weeks waiters
Interestingly, whilst the report found no correlation on the selection of variables covering primary and secondary care, it did identify 16 systems experiencing both relatively high levels of primary and secondary care pressure, including Bedfordshire, Luton and Milton Keynes, Kent and Medway, Leicestershire and Rutland, South Yorkshire and Sussex. A similar number of systems were found to be under low relative levels of primary and secondary care pressure including Bristol, Buckinghamshire, Oxfordshire and Berkshire West, Suffolk and North East Essex.
Harnessing data to support understanding of its role within place and neighbourhood is key to drive a whole pathway approach, system transformation and therefore elective care recovery across secondary care. Furthermore, the ability to examine data from multiple sources will provide a better understanding of the social determinants of health, the needs of the population and therefore, how to respond appropriately and address service variation.
The report also considered the relationship between patient experience and system pressures.
Interestingly, the analysis concludes that these pressures do not necessarily equate to ‘better’ or ‘worse’ satisfaction performance. An example being Gloucestershire, a system defined as having relatively high pressure, but recording high levels of patient satisfaction. Conversely, North Central London, regarded as being under relatively less pressure yet has high rates of recorded dissatisfaction with patients appearing to struggle to get appointments and attending A&E as a result.
Understanding patient expectations is key to ensuring the delivery of high-quality healthcare, moreso how to balance these expectations against clinician perspective, priorities, funding and service models. Improved understanding of the issues reported by patients will allow better targeting of resources.
The report concludes that given the different challenges each systems faces – for example, inherited socio determinants of health, demography, available infrastructure and workforce – there is not a one size fits all explanation, and therefore, one solution to alleviate the pressure.
In summary, a one size fits all approach to system planning and delivery is unlikely to work effectively. It is recommended that a detailed place-level analysis that understands the different needs of populations is essential.
Written by Wendy Bains