What does integration mean for health and social care?
Dr Derek Tracy
With the population growing, aging and living longer several critical, and increasing, pressures are pushing on health and social care.
Over the next fifteen years there will be a fifty percent increase in over 65s, and a quadrupling of those with four or more chronic health conditions (Kingston A et al, 2018). Over the past decade, NHS funding has grown by about one per cent per annum, a quarter of that recommended by the Office for Budget Responsibility to meet demand, and two in five NHS Trusts are reporting deficits. The NHS Long Term Plan brought a welcomed increase of 3.4 per cent, however this still may not cover what is needed (The Institute for Fiscal Studies, 2018).
Despite challenges, you could argue the NHS is still better supported than social care. However, there are over 100,000 unfilled posts in the NHS and social care, which will double by 2030 (Kings Fund, Health Trust and Nuffield Trust, 2018).
The push to ‘integrate’
We could try to do things differently: enter ‘integrated care’. Person-facing services that emphasise a strengths-based approach, community resources and social capital. Not a new idea, but increasingly promoted. The NHS Long Term Plan has now clearly set-out that ‘Integrated Care Systems’ (ICSs) of social and health care partners will plan, commission, and manage services, proposing legislative changes that will dismantle competitive aspects of the Health and Social Care Act 2012. However several key challenges remain.
What does ‘integration’ mean?
Descriptions of ICSs are purposely non-prescriptive to foster localism – what’s right for where you work? However, this means we have few road maps: is it all parts of the Local Authority and primary care? The acute hospitals to mental health? Shared human resources and IT? A focus on co-localisation is fine, but have you ever tried to get health and social care computer records to talk to each other?
If you had a blank sheet and could start again, what would you join: services for a population group such as older adults or children, or some other commonality, like physical health, mental health, and social care for people with schizophrenia? Lots of good ideas exist, but little to guide us; ultimately integrating systems will likely pragmatically go for what is possible – in terms of the teams and services that can and will come together locally – rather than what is necessarily optimal.
Winning hearts and minds on the frontline
I believe that the battle for integration will be won or lost through the engagement of frontline staff. Integrated care is attractive to most service users and senior managers like me, but presents unique challenges to staff. Most of us, whatever our roles, will get the potential gains, but integrated systems will force us to work in new ways, not just ‘more closely with others’. Despite their very many problems, our current systems support staff groups and our development; being a smaller part of a more heterogeneous system risks promoting generic working practices and lack of peer support.
In my integrating organisation, where we are incorporating mental health, physical health, and adult social care (what we called our three ‘tribes’), we argue this makes each background a minority. Whichever ‘tribe’ one belongs to, most others do not come from a similar place. How much will that matter? Might those in social care rebut that such a model still looks ‘largely healthy’ and worry about parity of esteem?
No doubt, integrated models also offer new training and development opportunities and an enriched work environment. To take another example from my experiences, a hugely positive aspect of this has been not just ‘working more closely’ but learning new ways to see old problems. I’ve hugely valued learning from physical health’s ‘no quibble’ system of seeing people, and the strengths-based enablement approach social care brings to the table. I think and hope that in turn mental health has brought a strong evaluative and research ethos to the mix.
How will we know if integration is working?
If it did everything it said, how would you know if an integrated system was ‘working’? Feedback, surveys, data on wait times? There are many interesting ideas, but a real challenge is showing causal change – that is to say change due to the new model – in a large system with so many moving parts. Moreover, one would predict the challenges of bedding in new systems will result in such indicators failing.
Despite that, if we are embarking on this wholescale change, we must be evaluating what we do, and disseminating learning – the bad as well as the good. There are no simple answers, and perhaps working with staff and those who use services is the best starting place: ‘what would tell us that we were succeeding or failing in two years’ time?’
I do not believe that any of these challenges are insurmountable, but they do need to be addressed. ‘Integrated care’ is a seductive idea – and we’re only too aware of the failings of the current models – but the details need fleshing out.
We are being pushed by deep national currents that will be hard to resist; our job is to engage but use this energy to ensure we are doing the right thing locally, working with staff and service users to make sure we have the right teams and people involved, that we are talking to others about what works and doesn’t for them, and measuring and reporting the results.
About the author
Dr Derek Tracy is a Consultant Psychiatrist and Clinical Director at Oxleas NHS Foundation Trust, and part of a senior management team leading an integrating health and social care directorate. He is also a senior lecturer at King’s College London. His combined clinical, managerial, and academic roles have made him preoccupied with trying to understand what ‘integrated care’, which has been strongly promoted by the recent ‘NHS Long Term Plan’ actually means, and how its success and failure might be measured. Derek will be speaking at our upcoming Leaders Forum.
Costs, complexity and compassion: Leaders Forum
26-27 September, Birmingham: view details
Leaders of services across the children’s and adults’ sector are navigating difficult decisions in which three factors loom large – the cost of meeting people’s needs, the complexity of the people’s lives and the interconnectedness of solutions, and the moral imperative to ensure that services and systems are grounded in compassion. Keeping all three themes in mind is no easy task, yet the evidence suggests that it is necessary to do so, if we are to design and provide services to meet the needs of children, families and adults.
Kingston A et al (2018) Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age Ageing 47, 374-380, doi:10.1093/ageing/afx201
Kings Fund, Health Trust and Nuffield Trust (2018) The health care workforce in England. Make or break? London: Kings Fund, Health Trust and Nuffield Trust
The Institute for Fiscal Studies (2018) Securing the future: funding health and social care to the 2030s. London: The Institute for Fiscal Studies