Integrated services reflecting individual needs and marshalling skills and resources across the health and care sectors for the right people in the right place at the right time. That’s what we should have now after 60+ years of a nationally funded health service. But we don’t have it and in some places things are becoming more fragmented as clinical networks break up in the post-PCT confusion of emerging clinical commissioning groups. A recent case in point is the National Audit Office’s damning inquiry into services for people with neurological conditions like MND, Parkinson’s and MS identifying persistent disconnects and failings around emergency admissions despite massive investment. More money doesn’t automatically mean better outcomes.
“Improving outcomes by working together”
That’s one reason why the joint Kings Fund/Nuffield Trust recommendations to the Future Forum and the DH on integrated commissioning are worth your attention. Have they found the answer? Is this the map to the Holy Grail? Much as we would like to be believers, we remain doubters. There is much more to “improving outcomes” than simply “working together”. Here’s why.
Only a few pages into the report it is quickly apparent that merger and even institutional integration between health and social care is not on the agenda – not this one anyway. What they are talking about is integration of services around the needs of individuals (elderly people, children) with complex needs and many others with long term needs, including end of life care. That is all to the good but not new. It should have happened a long time ago of course. There is already a guide to this, the National Voices Principles of Integrated Care which the latest report endorses – and rightly so.
Social care elephant in the room
There is a big policy elephant in the room: the vexed social care resourcing issue. The report merely identifies this as a “barrier” to integration. That it certainly is and the explosion it is going to cause this spring when we finally have to bite the bullet on how to fund social care will rock the political foundations. But by far the biggest barrier to integration is the acute-focused clinical culture of most of the NHS and the local authority protectiveness of much of social care. These are like oil and water and, frankly, they need nuking. Our view is that without organisational integration, common pots of money and buckets of inspirational and innovative leadership in the professions and councils, the “pace and scale” of change which the report says is vital is unlikely to happen. There are too many vested interests conspiring against it.
Patient and carer power?
Could patients and carers not rise up, charge the barricades and demand integrated services? We’d like to see it happen. Individual budgets may be one way to tunnel underneath the obstructions. But it is not sufficient to talk, as the report does warmly, about personal health budgets. That is only part of the picture: we need integrated health AND care budgets for individuals – at realistic levels – as anyone with a long term condition will tell you who uses services across the sectors.
Patients and carers could leverage more power in the system in their role as budget holders. But they need brokers and guides to act as agents and facilitators with service providers if they are to maximise their purchasing power and not to get ripped off. Here is a big opportunity for 3rd sector bodies and for specialist clinicians like neurological nurses – will they rise to it? We’d like to see that, especially now that there are strong signs that the NHS pension scheme will be extended to non-NHS providers.
More radical thinking needed
The report is a prompt to address the cultural and institutional blockages stopping integration. It is not just about resources. It is about more subtle things, including professional leadership and personal fulfilment. Peter Carter made this plain before the Health Committee last month: the impulse of good practice like integrated services has to be “encrypted into the culture”. Florence Nightingale might have said it differently, but not any better.
Until we develop more capacity in primary and community health care to deal with demand outside of hospitals, too many elderly, frail people and others with complex and long term conditions of all ages are going to end up there by default as the NAO report on neurological services shows. This is bad for them and bad for the institutions that have to receive them.
The reality of NHS provision – and it does not have to be bricks and mortar, there can be “virtual wards” in the community – has not matched the political rhetoric about this goal. All governments share the blame here and a few glib targets will not turn the situation around quickly. Just look at who is occupying a high proportion of acute beds to see what the problem is when people cannot be cared for at home or in intermediate settings which are better and safer for them. Better yet, we need to prevent a much higher proportion of unplanned admissions in the first place.
Health and care are a continuum. We must break down the funding and cultural barriers between the health and care sectors and the rivalries and turf wars between professions. To achieve integrated services, professionals must do this in in partnership with patient leaders.
At bottom the Kings Fund/Nuffield report is well intentioned but simply does not go far enough with radical thinking. The owners of the services – that means the public who pay for it and the people who use it – should demand nothing less.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.