In his 2015 spending review, former Chancellor George Osborne said:
“The spending review sets out an ambitious plan so that by 2020 health and social care are integrated across the country. Every part of the country must have a plan for this in 2017, implemented by 2020.”
If this element of the 2015 spending review survives the post-referendum change in ministers, it raises a number of questions, starting with: Does your area have a plan?
The drive towards health and social care integration is not new. It was re-emphasised in the Health and Social Care Act 2012 and the Care Act 2014 and has been championed by successive governments. In 2013 and 2014, the Better Care Fund was established; while this was primarily to provide for pooled funding for out-of-hospital health and social care, its focus has become increasingly tied to the prevention of hospital admissions and the speedier discharge of those ready to leave hospital.
Approaching this from the service user end may perhaps be more productive. Viewed from here, integration is more about the effective and seamless provision of services that meet the individual’s needs and which do so in a way that does not create unnecessary barriers or cause unnecessary breaks in the provision of care.
There are several good examples of services which either achieve or approach this, but one of the difficulties has been moving from potentially isolated small scale examples to effective system-wide working. A number of tools can be used, but there are also some quite serious questions to be answered in planning and developing something that will suit any individual locality.
It needs to be borne in mind that health and social care do not always work well together; neither do different parts of the health system. From time to time the different organisations give the impression of almost turning their backs on each other to focus on internal issues at the expense of cooperation.
There are a number of issues that can arise: some of more general application and some that are specific to individual localities. First, there is the fact that, having developed separately and with separate statutory frameworks, health and social care remain two very distinct tribes, with different approaches to the organisation of work, the concept of commissioning and the role of central government. There are also material, and potentially quite divisive, issues over the ability of local government to charge for services in certain circumstances. This is something which is generally not available to the NHS. The NHS has often been criticised, most recently by Lord Porter, for ineffective financial management and, in many areas, there is mutual distrust of the potential risk created by perceived funding shortfalls on the part of the other partner.
There are also significant difficulties created by the fragmentation of the NHS in the aftermath of the Health and Social Care Act 2012 and some of the disconnects that exist between the relevant areas and between Clinical Commissioning Groups and local government. A further complication in a number of areas has been the advent of children’s trusts to take over what are perceived as failing local government
children’s services.
One key factor for any effective integration of services between different professionals – whether they are employed within the same organisation or not – is the ability to ensure that the professionals have access to relevant information about the client. This information needs to avoid the repetitive explanation of symptoms and history to frequently numerous different emanations of the health and social care system. This requires effective information technology and transfer to provide for the interoperability of systems and the delivery of accurate, up-to-date information about the service user to all professionals who need access to it. It also needs to be underpinned by effective information governance.
Having common information is a starting point. The next step is to ensure, as far as possible, that there is no duplication between different contacts with the service user. This has the potential to deliver efficiency savings so that fewer visits are needed and, particularly in the context of home visits, there can be a reduction in the number of people having to lose time through travel to get to the service user. This should also be extended to having consistent, coherent and as simple as possible patient pathways.
This may require some work in developing skills for the relevant professionals so that they are able to undertake a wider range of activities. It will also require an effective organisation sitting behind the services so that at least there is a unified mind or consciousness in planning the services to be provided for the individual. How this is arranged may vary depending on the local arrangements. It may work through effective joint commissioning or lead commissioning or through an accountable care organisation responsible for the whole of the care, whether or not it then goes on to deliver it. It may also work through effective alliance mechanisms which translate into effective virtual or real multi-disciplinary teams dealing with the individual.
One of the perennial problems has been money and, more importantly, avoiding the problems caused where savings in one place are generated by expenditure in a different budget or in a different year. Pooling budgets can help with this, although the current limitations under section 75 of the NHS Act 2006 may mean that organisations want to look at the use of aligned budgets – as already happens in Plymouth – or other forms of integration under the Act. However, this is a big area where uncertainty about the adequacy of budgets across the economy is an inhibiting factor, as illustrated by Lord Porter’s comments criticising the lack of the equivalent of local government financial controls in health. The effect of an integrated provider may be to circumvent some of these issues, although the financial management pressures may merely move if the demand risk is transferred to the provider under a capitated budget.
One aspect of this, which can have some short-term results, may be to invest in identifying individuals who are high cost or frequent users, and look at them individually to review how a more interventionist approach may be able to establish a more planned relationship with services. Another more service level approach is that adopted by NHS Right Care which asks: Where are you spending above average for below average results, and what are others doing in relation to these? Some of the answers may sit firmly one side or the other of the health and social care divide. If you start with the mindset that, however it is structured, there is one pot of money for the health and social care economy, which should be spent in a way that gets the best results most efficiently, you will be on the right track.
This more interventionist approach also underlines the need to involve preventative action, particularly through public health. In the long term, we need to see a greater proportion of the population enjoying better health and not necessarily looking to public services to help them deal with the consequences of poor health and social care needs.
We would emphasise that there is not one single solution, as local structures and needs may indicate different approaches; however, there are some common themes:
Do not expect big changes to be implementable quickly.