The F word seems to be flavour of the month again. I mean fragmented. Commissioning and services are ” fragmented” in public health, it seems and this ” needs to be laid at the door of the Lansley Reforms in 2012.” That’s how the narrative goes.
It’s not as simple as that, even for those who might want it to be. The 2017 PHE Report on sexual health is often quoted as evidence for this despite the report had much more good to say about sexual health services than it did about fragmentation. A BMJ article from 2014 describing an FOI survey of commissioning is often cited as evidence for this post Lansley fragmentation. Despite the fact a similar article in the same year in the same journal decried “weak and fragmented” intra-NHS commissioning as “threatening improvement.”
The debate and discussion around fragmentation is too simplistic and historically selective. And it’s time we resolved this. And here I want to try and set this debate about fragmentation in context. For this blog I am going to concentrate on Sexual Health Services. I’ll turn to others in due course.
Fragmentation has always been with us
While there is fragmentation in provision and commissioning, the idea that this was somehow originated in the transfer of public health services to local authorities in 2013 is simply untrue. And this idea that it’s only in public health services and not elsewhere in care is, as we’ve seen above, just plain wrong. While that doesn’t excuse current fragmentation, this kind of simplistic “blame it on Lansley” analysis is nothing like the whole story and takes us nowhere forward.
Fragmentation remains a perennial challenge in health systems. A World Health Organisation technical briefing on Integrated Care in 2008 said fragmentation in services remains too depressingly the norm not the exception. A series of papers in the Annals of Family Medicine from 2009 made this clear with a global perspective on fragmentation,
A Royal College of Physicians report in 2015 concluded that services which often remain entirely within NHS commissioning arrangements are too often fragmented. Sir John Oldham’s 2014 report on fragmentation on whole person care in 2014 concluded that the NHS and Care System was systematically not good at joining things up
The idea that this is something public health services face alone is simply not tenable. The King’s Fund Integrated Care programme in 2011 actually produced five principles of integrated care to try and help resolve fragmentation.
Fragmentation in HIV and Sexual Health Services
There is an easy assumption by some that fragmentation in sexual health services arose since 2013. This is not true. MedFaSH in a 2008 report identified fragmentation while services were still entirely commissioned within the NHS, and made clear some of the mechanisms of this were about poor commissioning, inconsistent application of payment by results tariffs and lack of people working together.
The Royal College of Obstetritians and Gynaecologists in 2011 decried Womens’ Health especially reproductive and sexual health as fragmented and not joined up. The European Forum for Primary Care in 2010 said sexual and reproductive health fragmentation was a problem across Europe. Going as far back as 2004 the National Manual for Sexual Health Advisers described a history of service fragmentation right up until a National Sexual Health Strategy in 2002. The Department of Health’s own 2008 Gender and Access to Health Services Study described fragmentation across services for many people. A 2010 report for NICE decried fragmentation in sexual health and reproductive care for pregnant women.
A civitas Study in 2011 called London’s HIV services often too fragmented. The House of Lords Select Committee in 2010 identified fragmentation in HIV services as a major challenge. The London TB Services Needs Assessment in 2011 concluded that “TB service provision is greatly hindered by the fragmentation of services in London.”
You’ve probably gathered by now that I could adduce many more examples, but the point here is obvious : this fragmentation was going on while all services where still commissioned within the NHS. And for those of us with a long memory, there were some things that were much worse in sexual health and HIV services during this era.
I’m not claiming that any of this makes fragmentation justifiable. But I am arguing that we must get better at arguing what is now fragmented and how we resolve it. The sloppy “just turn back the clock and put it back in the NHS” argument doesn’t help anyone. It’s time we ditched the spectacles which rose-tinted anything before 2013. For every service which had a golden age because of a committed and interested commissioner re-2013 there were others who were starved of funding and interest.
It’s also time we recognised that some of this is narrative is informed by ideological opposition to health services being commissioned or provided by anyone other than the NHS. Whether that’s right, wrong, supported or contradicted by the facts on outcomes and spend is for another time. But I will say that that this argument is a slap in the face to committed voluntary sector and local authority colleagues, never mind what anyone thinks of commercial sector providers .
I do, however, maintain that getting your history of fragmentation entirely wrong in support of this ideological argument is sloppy , doesn’t stand up to scrutiny and doesn’t serve anyone.
Ditch the pre 2013 rose-tinted spectacles
For me, fragmentation raises some systemic issues. Seeing those in the light we need to is not helped by ahistorical assumptions that all was well when services were in the NHS.
It is also not helped by a lack of recognition that some things have improved, despite much more work needing to be done, and despite the deliberate policy choice of government to cut these services.
Public Health England evidence to the Health and Social Care Select Committee had some good things to say about Sexual Health since the transfer, as did the 2017 report I alluded to earlier. And The Economist has just highlighted innovation in sexual health services which it says the rest of our health and care system could learn from.
Where next? Systemic approaches to reducing fragmentation
Let me go back to the King’s Fund Integrated Care programme in 2011 five principles of integrated care . That needs to be one starting point. But another needs to be taking our hands off the levers of structural reorganisation and locking those levers away for a few years.
In other words, starting with people not responsibilities, and starting with outcomes not services, has shown significant benefit in a range of places.
I think that logically some of this is actually quite simple, but fiendishly difficult in practice. First, stop messing about with yet mote structural reorganisation. It hasn’t solved anything and there are hectares of studies which show this approach should be the last option. Second, focus on the culture of different players in the system and make them work together to join up services, with patients and clinicians core to this. A key variable in the countless research studies on health and care change is culture and empowerment of players to find solutions.
Yeah, I hear you saying you’ve tried it. But actually it has worked elsewhere. There are several keys to this – we need to stop treating public sector organisational culture change like a recipe or machine “pull a level and hey presto”. It’s much more complex. Insights from health and care quality improvement should teach us that.
Third, invest in the capacity and quality of commissioners and commissioning. And do commissioning better. You’d be amazed at how much can be done within existing mechanisms, structures and systems. I’ve seen it personally. And I’ve also seen how poor commissioning practice has caused problems in several places. We need a proper appraisal of what that means. But the simple “procurement bad” logic needs to be set aside. It’s not as simple as that.
Some places have found very simple solutions by joint commissioning vehicles. Others have found the most mature commissioners take a partnership approach with providers to quality, outcomes and reducing fragmentation. It can be done. Others languish because we can’t get NHS England to the table for love nor money, or the lobbying and ideological interests of some players in the system sets their faces against solutions because the pre-2013 world was better for them.
Let’s start this discussion again.