Dr Stephanie Coughlin
GP and Chief Partnership and Place Officer, Homerton Healthcare NHS Foundation Trust
Integrated care has long been a cornerstone ambition for the NHS. Yet despite years of policy focus, pilots and structural reform, many of the same challenges persist. In our recent NAPC Live, Prof Andy Brooks spoke with Dr Stephanie Coughlin, GP and Chief Partnership and Place Officer at Homerton Healthcare NHS Foundation Trust, to explore why.
Drawing on her recent MBA research, Steph shared practical insights into what is really happening beneath the surface of integration efforts and what leaders can do differently.
A system designed for hospitals
One of the most striking reflections from Steph’s research was a quote from an interviewee: the NHS is “a system perfectly designed to keep care in hospitals.”
This highlights a fundamental tension. While there is widespread agreement about shifting care closer to home, the system’s incentives, structures and habits often pull in the opposite direction.
Consensus on the surface, disagreement underneath
Steph’s national survey of 330 health and care professionals revealed strong headline agreement about what services should move into the community:
- 81% said long term conditions
- 64% said frailty
- 61% said end of life care
But dig deeper and the picture becomes more complicated.
“Long term conditions” meant very different things to different people. For some, it meant relocating hospital clinics into GP surgeries. For others, it meant building neighbourhood teams that address wider determinants like housing, loneliness and financial insecurity.
The lesson here is simple but powerful: shared language does not equal shared understanding. Without getting into the operational detail, teams risk thinking they are aligned when they are actually working towards entirely different models.
Reframing the question: what must stay?
A particularly useful insight from the research was flipping the usual question.
Instead of asking what services should move into the community, Steph suggests asking:
What must stay in hospital?
When explored in practice, the list was surprisingly small. Intensive care, some surgery, maternity and certain inpatient services.
This reframing helps teams think differently and opens up more ambitious conversations about what can genuinely be delivered in neighbourhood settings.
The leadership divide we need to talk about
Perhaps the most striking finding was around leadership.
- 58% of primary care respondents preferred a primary care led model
- Only 6.1% of other NHS respondents agreed
This 51.9% gap was the largest divide in the whole study.
It reflects real concerns. Primary care worries about being overwhelmed or absorbed. Larger organisations worry about accountability and delivery at scale. Meanwhile, “partnership” is often used as a catch all phrase without clarity on who is ultimately responsible.
There was agreement on one thing though: clinical credibility matters most. When pushed to prioritise, professionals value leaders who understand frontline care.
Moving beyond vague partnerships
A key takeaway is that language alone is not enough. Saying “we will work in partnership” does not resolve questions of accountability, governance or risk.
Instead, integration needs:
- Clear roles and responsibilities
- Honest conversations about organisational pressures
- A shared understanding of different business models
As Steph highlighted, even basic realities such as the financial risk carried by GP partners are not always understood across the system.
Start small, build trust
So what works in practice?
One consistent theme from the interviews was the importance of starting small:
- Focus on one or two shared priorities
- Create tangible projects that teams can work on together
- Build trust through delivery, not just strategy
Real collaboration happens when operational teams work side by side, not just when leaders agree high level ambitions.
There is also value in using existing resources creatively, particularly people. Integration does not always require new contracts or funding from day one.
Measuring what matters
Another challenge is how success is measured.
Current metrics often focus on hospital activity. But integrated care is just as much about what doesn’t happen:
- Prevented admissions
- Improved self management
- Better population health outcomes
Shifting towards prevention requires new ways of measuring impact over longer timeframes.
Final reflections
Steph’s research reinforces that the barriers to integrated care are not just structural. They are cultural, operational and relational.
To move forward, we need to:
- Be precise about what we mean
- Have honest conversations about leadership and accountability
- Focus on practical, shared delivery
- Invest in relationships over time
Integration is not a quick fix. It is, as Steph described, “a slow burn” that requires constant attention and effort.
Watch the full webinar
To hear the full conversation, examples and insights, watch the full webinar. You can become an NAPC member for free to access this and a wide range of exclusive content, events and resources.
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