Integration is a current buzzword in healthcare circles, seen as a potential way of saving billions of pounds as well as improving outcomes. But what does it mean, and will it work?
Sir David Nicholson, head of NHS England, has told the NHS to make efficiency savings of £20 billion between 2011 and 2015. But these financial pressures coincide with a rising need for care among older people and those with chronic illnesses and disabilities. In such a context, the Nuffield Trust estimates that the NHS faces a £29 billion a year care gap if services are not provided more efficiently. Unless more funding becomes available through tax rises or a miraculous economic recovery occurs, whichever government is elected in 2015 faces an enormous challenge.
Ed Miliband has recently cottoned on to the severity of the crisis facing the NHS. His response has been to follow in the footsteps of many a politician facing a difficult problem, and set up an independent commission. It will be chaired by Sir John Oldham, a former senior clinical manager at the Department of Health. His brief? To develop proposals for integrating physical and mental healthcare with social care, in an attempt to reduce duplication.
Oldham has a challenge on his hands. He has been told that his reforms must not incur extra costs nor lead to any more top-down reorganisations. This seems to be something of a contradiction. Knitting together three services which have different histories, cultures, managements and staff is a laudable aim, but one which will inevitably involve considerable reorganisation.
Challenges and opportunities
Firstly, there are no quick fixes. Reshaping health and social care requires vision, leadership, time and persistence. It involves planning and consultation with healthcare professionals and local authorities as well as local communities, patients and service users. A King’s Fund study of service integration for older people in Torbay reveals that it took nearly a decade for services to evolve from small beginnings to “system change”. Nor is it a route to quick savings. Integrating services in the long term may well save money. But it is unlikely to deliver significant savings in the early years due to the complexity of the process.
That complexity is worsened by the fact that the NHS has just been subject to increased fragmentation as a result of hotly contested government moves to increase competition. This will undoubtedly make integration more difficult, as providers proliferate and competitive tendering becomes the norm.
Meanwhile, social care is a Cinderella service, barely fit for purpose and in urgent need of a thorough overhaul. Social care is increasingly hard to access, expensive unless you are very poor, lacking in quality and not focused on the needs of patients and service users.
The thorniest issue of all is likely to be funding. The NHS provides a universal system of healthcare still largely provided by the public sector, free at the point of use, and funded through general taxation. Social care, by contrast, is increasingly provided by the private sector. What remains of the publicly-funded system is focused on those with the highest needs and lowest means. There is widespread public support for the NHS to continue providing free care. Ideally social care provided by an integrated service should also be free and funded by taxation. However the prospects for this do not look promising in the current economic climate. Full implementation of the Dilnot Report’s proposals, not the watered down version presented in the Queen’s Speech, would be a step in the right direction.
It is certainly to be hoped that the commission will resist the temptation to locate a unified health and social care service in local authorities. Many council social services departments have little concern for quality issues. They are also significantly less responsive to patient and service user needs than the NHS is.
There are of course opportunities as well as challenges. Thinking about an integrated service provides an excellent opportunity to listen carefully to what patients and service users (and their families and carers) say about their experiences of care. These views, together with those of staff, can be used to co-design services.
There is also interest in the possibilities created by scientific advances and new technologies, as well as changing professional roles, new information and communication technologies and a big increase in the health-related information available to clinicians and patients. Integration is one attempt to embrace these changes.
Past, present and future
The NHS was founded in 1948 in a period characterised by optimism, egalitarianism, collectivism, and Fordist ways of providing state services. The culture of this period has been captured in Danny Boyle’s opening ceremony for the Olympics, Ken Loach’s film, The Spirit of ’45, and discussed in Roger Taylor’s recent book, God bless the NHS (co-published by Guardian books).
Healthcare has been considerably reorganised over the past three decades. The creation of an internal market, the introduction of Foundation Trusts and the greater use of the private sector have significantly changed the NHS – and technological change and the rise of consumerism have changed society more broadly.
We are also entering a period in which policy makers are keen to emphasise the need to move some services out of hospitals and ‘closer to home’, where the boundaries between health and social care are more blurred.
The goal of integration could take several different forms, ranging from market solutions at one end of the spectrum to traditional NHS solutions at the other. It would be undesirable in the eyes of many (including myself) if integration extended marketisation and the use of the private sector in the NHS. But the days of a ‘one size fits all’ service are over. We must hope that in developing a new model of integration, Miliband’s commission will retain a strong commitment to NHS values, learn from the diverse experiences of patients and service users, and encourage innovation in service reorganisation.
An outbreak of consensus?
Hot on the heels of the Labour Party’s commission, the government has unveiled its own proposals for integration. These aim to close the gap between health and social care by 2018 and to establish some exemplary ‘pioneer projects’ by this autumn.
Such moves are a step in the right direction but raise a number of questions. How will the ‘pioneer projects’ be funded? An accompanying document, Integrated Care and Support: Our Shared Commitment, states that the funding should come from clinical commissioning groups. But evidence from existing projects suggests that integration can be costly in the short to medium term. Without additional money investment will have to come from efficiency savings or cuts elsewhere.
A further question concerns the difficulties of integrating two systems of care, governed by different principals and very different funding mechanisms. How can we be sure that integration does not lead to charges for services which are currently free to everyone who needs them?
The two services have very different cultures, with the NHS at its best being significantly more service user-focused than local authorities and the private agencies which provide most social care. The dash for integration is occurring primarily because of economic pressures. It would be a tragedy if more integration were to result in NHS services being reduced to the poor quality of social care ones.
Monitor, the sector regulator, has a duty to enable integrated care as well as to regulate choice and competition. Tony Lambert, director of strategy and policy, maintains that effective regulation of choice and competition will be vital in enabling integrated care to flourish. But evidence from existing projects suggests that developing sustainable integrated care is a slow and painstaking process, requiring trust and a shared vision. Charities and third sector organisations may well have a role to play. But it is hard to see how most organisations with an eye on profits and the next round of competitive tendering will be able to work in successful long-term partnerships wth NHS and other public sector organisations.
Of course private sector organisations may bid to run integrated services themselves. Virgin Health has recently won a contract to provide integrated children’s services in Devon. For this to set a precedent would be lamentable. There would be no guarantees that private providers would be in it for the long term, significant NHS professional expertise would be lost and a crucial and growing area of care would be subject to economic competition.
The NHS and social care sectors are full of silos and neither is renowned for innovation. Think tanks including the King’s Fund have been suggesting for some time that some aspects of policy and regulation act as barriers to coordinated care. Norman Lamb, Minister for State for care and support, uses the language of innovation and “pushing the boundaries”. But will the national organisations signed up to the government’s proposals really encourage innovation? Especially if it involves patients and service users co-designing services, or requires additional money?
What kind of future?
In the brave new world of integration we could be looking forward to a system in which patients and service users enjoy high quality joined-up care, partnership working, and choice and control over where and how they are treated.
We could however be facing a grimmer future with another under-funded system, mired in bureaucracy. A system, for example, which has been designed to solve specific problems (for example patients staying too long in acute hospitals, or pressures on A&E departments) but which fails to put patients and service users at its heart.
I hope that the Labour Party and the government are not just looking for cheap quick fixes. They need to be aware of the pitfalls as well as the opportunities and do everything they can to ensure that an integrated future is a good one. Older people and people with chronic illnesses and disabilities deserve nothing less.