Integrating health and social care make sense. In an ideal world it should mean people spend less time being passed between acute, community and social care services (based on their immediate "need") and ultimately get to spend more time within their own communities and in their own homes. It also makes financial sense in terms of managing demand for expensive hospital beds and services and keeping overall costs down.
As far as I am aware, despite the change of Prime Minister over the summer, the ambition is still for NHS services and council-led adult social care services in England to be fully integrated by 2020. The current efforts to achieve this are being driven by the "Sustainability and Transformation Plans" being drawn up in 44 local areas.
The theory of integration is relatively simple - two or more services which sit along a typical service user pathway are brought together in a manner that will improve and simplify the service user's experience. However, in reality that means two or more organisations, with different cultures, different professional languages, different budgets and different incentives coming together. NHS staff tend to focus on treating specific, identified issues whist social care staff tend to be more focused on helping people live lives they want which is often harder to pin down and might.
social care services under "budget pooling" arrangements. In October last year, Torbay and South Devon Foundation Trust became the first Trust in England to join-up acute and community care with adult social care. Earlier this year Salford Royal NHS Foundation Trust took over the running of adult social care services as part of newly established Integrated Care Organisation. While housing these services in the same organisation is a good start, there is an additional difficult and disruptive process required to produce a seamless, integrated service.
So what would really good look like? In Canterbury, New Zealand, they have managed to properly pool budgets and develop genuinely joined-up acute, community and social care services where patients don't have deal with a whole range of different providers to get support they need. They have developed concepts like family health care centres, which have led to a big increase in people being treated in their own communities and at home rather than in a hospital.
The truth is we aren't anywhere near this in England. So what is stopping this from happening?
Lack of genuine partnership working between the NHS and councils - Unfortunately, in many areas, the engagement between the NHS and councils has been pretty poor. Council are smaller partners in terms of budget but should be major partners in terms of delivering a joined-up service. The recent press has been full of council leaders venting their frustration at their lack of involvement. Council must be equal partners around the table for this to work.
A regulatory environment which encourages a "fortress mentality" - The Kings Fund has analysed the progress of STPs to date and they rightly point out that the regulatory and accountability environment encourages a "fortress mentality" rather than collaboration. Driven by their mandate, organisations like NHS Improvement and CQC take a focused view of individual NHS organisations rather than the whole health economy. So there is currently little incentive for NHS organisations to sacrifice for the good of the system and this has resulted in the STP process being more focused on short term financial sustainability rather than about real integration of services. The result is a "command and control" leadership style rather than the collaborative, compromising leadership which is needed to make integration work.
Councils and the NHS have totally different financial requirements - Unlike the NHS, councils are legally bound to run a balanced budget i.e. spending has to match income, whether through central government funding or local taxes/charges. This requirement is forcing them to think creatively. Councils are increasingly looking at "spinning out" services into local authority trading companies (which are owned by the council but can act like businesses), staff-led mutuals and various forms of joint venture (including with the private and third sector). There is no such requirement to balance the books within the NHS which, naturally enough, curtails innovation around new delivery models. Why would any service operating under such protective financial conditions want to move to a new model where it might lose that? If you are interested, Lord Kerslake has highlighted this issue in an excellent article for King's Fund.
If we want properly integrated care, like they have in New Zealand, we need a system which will encourage organisations to come together and form new delivery models. This is where the real innovation will come but it will mean losing the "fortress mentality" that currently dominates the system. We need greater incentives for councils and the NHS to work together, including looking at how NHS Improvement regulates individual organisations vs the whole health economy. Maybe it's also time to start treating councils and the NHS equally in terms of running a balanced budget - but it would take a brave politician to tackle that one...Suggest a correction