The concept is not new, however the complexity of our system means that there are many areas that gaps can occur, with various models and approaches to implementation across the country, ranging from the NHS combining its own assets in a geographical area (vertical integration linking GP practices, community and hospitals), or collaboration between health and social care professionals across organisations (horizontal integration).
These health and social care “systems” may combine into a single new organisation or form an alliance (typically by contract) binding a network of separate providers to the same outcomes and goals. The advent of the Better Care Fund and new joint commissioning arrangement are real-life examples of the latter. As we are essentially dealing with people, organisational boundaries and behaviour change there is no quick or ‘off-the-shelf’ solution to integration.
Bloom conducted an interview of our Head of Strategy and Performance, Simon Whitaker, who responds to questions on the challenges faced by the public sector when moving to an integrated health and social care system, as well as the tangible benefits integration can bring to the end system user.
Why is integration needed?
Typically, mass crisis leads to mass change in any system. The end of the Second World War brought about many changes to the welfare state, contributing in large part to the establishment a free NHS and a means-tested social care system back in 1948. However, over the last 70 years this structure has remained largely in place, despite huge changes in the population, technology and economy, which has led to our current system fragmented system, meeting poorer outcomes for individuals and growing inefficiencies. Culturally, we have struggled to bridge this gap.
The gaps are apparent where a patient needs to move from formal ‘paid for’ healthcare in hospital and transition to home care, often leading to delays, including a lack of focus on public health campaigns, preventative and wellbeing services – only now are we starting to realise the benefits of reablement. There are also additional complexities such as Continuing Healthcare which becomes means-tested unless a ‘primary health need’ has been agreed through the process of assessment.
As we have seen through the current pandemic, there is huge disparity between health and social care – not just within the sector but from the perception publicly. In just six weeks, over £100 million has been raised for NHS Charities Together, which shows the huge swell of support for a critical part of our system and demonstrates that we still have a cultural commitment to maintaining core health services as free at the point of need.
Simultaneously, it has taken several weeks to recognise the integral work the care sector deliver – the retail discounts, free meals and ‘protect our social care’ slogans were slower to reach this sector in March and April. Indeed, it would appear that the decision to discharge hospital patients back to residential care without testing and completion of quarantine in some cases, not only exacerbated the mortality rate, but demonstrated a lack of understanding of the sector.
Despite employing even more than the 1.5 million people working in the NHS and providing services to more than 1.7 million adults and children at any one time, social care is plagued by misunderstanding around who it is for and what it can provide. Integration is not just about bringing services together, but using the huge pull and attraction of the core health services we value to create a new paradigm for health and social care.
What does it mean for health and care service users?
In short, the benefits would hope to be seen largely at the interface between health and care systems – a reduction in wasted effort, better transfer of information from one professional to another, less overall transactions and a more joined-up leadership which recognises, and can put in place, the right care arrangements at a local and regional level for their populations.
However, if the system aligns itself well during integration and beyond, there are tangible and practical benefits that can be gleaned for the whole population, particularly for the growing number of people living with multiple long-term conditions. These benefits include:
- Improved outcomes and patient experience (a single care journey agreed by all): including an assessment that follows a patient/service user in their journey from home to ward and any subsequent care setting. A patient who can be assessed once and have a health and social care team around that agrees with – and can put in place – the care needed will significantly reduce the delay and debate that causes individuals to fall through the cracks in the current system which, in turn, can exacerbate demand.
- Financial Efficiency (shared resources and reduced duplication): a system that pools knowledge, expertise and financial resources is better equipped to meet future demand in these financially challenging circumstances. It would mean more effort and focus put into preventative measures and public health and focus on upskilling and using a multi-skilled workforce to deliver a range of health and care tasks rather than relying on specialties and traditional health/care role types. The role of Trusted Assessors and the Home First model are just two examples – helping to support people in the gaps between health and care that enable individuals to recover faster from illness or injury and maintain a better, more fulfilling quality of life for longer by being in the right place at the right time for care to be delivered.
What lessons can we learn from the recent pandemic?
On the 26th March the HSJ published ‘Coronavirus is a true test of integration’, authored by Sharon Brennan. In compiling the article, the author interviewed key health and social care leaders who articulated the pace at which barriers to working together (health and social care systems) had been overcome. There are tales of obstacles which had been debated for months if not years being overcome in a matter of days – this in no small part has been due to a common desire to save lives. Whilst some of these decisions have come potentially at the detriment of social care, such as the policy of discharge to residential care, the central tenant of having a common goal has the potential to drive future integration.
Concerns as to whether local authorities are full partners in these integrated care systems (ICS’) or simply stakeholders have been addressed. Indeed, the speed at which thousands of people were safely discharged to make hospital beds available demonstrates the importance of this partnership and would not have been possible without the hard work of social care colleagues. A&E admissions have fallen to their lowest in 10 years (for better or worse), and the concept of DToC has largely become a myth relegated to the annals of history.
We’ve reduced demand to a level we thought it may take years to crack, in a matter of weeks. The trick is, of course, to sustain this level of demand in a measured way whilst ensuring we still support those that are most vulnerable. In addition, funding packages and other schemes have been much quicker to come down the line than previously planned (see the Enhanced Health in Care Homes package brought forward by 6 months to support care homes in the pandemic, and an addition £600m released directly to support providers in supplying PPE to their workforce).
Overcoming professional tribalism and organisational boundaries to overcome challenges with a common goal of improving the lives of end users has to be at the heart of future integration. The slow and quiet introduction of the ‘CARE’ brand, to stand alongside the NHS, is a start, but by no means an answer to bringing parity to a wide a diverse system. It’s my opinion that rebadging our system the National Health and Care Service (or NHCS) would have been even better, however it’s important to remember what a diverse and fragmented system social care has been and that the journey is still long, albeit we are now on the path.
Achieving the benefits of integrated care requires strong system leadership, professional commitment, and good management. Systemic barriers to integrated care must be addressed if integrated care is to become a reality, in this regard the current pandemic has shown us the art of the possible and should give us a basis upon which we can build.