Horizontal or Vertical: Which way to integrate?

Abstract

In 2011, Primary Care Trusts faced a difficult choice. The Transforming Community Services policy required a complete break of commissioner and provider functions. But what should PCTs do with the community health services they delivered; vertically integrate with an acute trust, horizontally integrate with a mental health trust, or set up a stand-alone community trust or Community Interest Company? Seven years on, this report explores the impact this choice had on the level and growth in emergency hospital use in older people and considers the wider implications for the NHS as it develops new models of care and integrated care systems. Boards and senior managers making decisions about whether to structurally integrate services are not well supported by research on the subject. The relative merits of vertical (i.e. acute-primary) or horizontal (i.e. primary – community / mental health) integration are also not well established. The paper focuses on the impact of changes to district nursing services (the largest service subject to the Transforming Community Services policy) on emergency hospital use of older people, a key metric of interest for national government. Whilst no single metric can adequately describe the functioning of a health and care system, the rate of emergency hospital admissions and bed-days provides insight into how well the main components of a system work together to manage patient care proactively. The paper seeks to answer the following question: Does structural integration of district nursing services with acute or other community health services have an impact on levels of emergency hospital admissions of older people? It also encourages reflection on policies that lead to structural change. In 2010-11, emphatic and definitive claims were made about the benefits of Transforming Community Services. Substantial resources were used to develop plans and extensive assurance processes were put in place to check that these would deliver the changes required. But as far as we can tell, no attempt was made to test whether the promised benefits were realised. Eight years on and familiar claims are being made about benefits of structurally integrating services. Management teams are exploring options and developing plans and regulators are establishing new assurance frameworks. The question of whether and how to structurally integrate services lies at the heart of this process. This paper attempts to draw out the lessons from Transforming Community Services for those wrestling with this question.