Soup or salad? It’s time to rethink health and care integration

For decades, the debate about integration has focused on structures, systems and services. Former ADASS President, Jess McGregor, argues that we need to turn the question around – starting with the life someone wants to lead and asking how health, care and communities can help.

For decades, the debate about integration has focused on structures, systems and services. Jess McGregor argues that we need to turn the question around – starting with the life someone wants to lead and asking how health, care and communities can help.

We’ve been talking about integrating health and social care for most of my working life. But I sometimes wonder whether we’ve spent so long talking about how to integrate that we’ve lost sight of what integration is actually for.

Surely the starting point isn’t a vision for beautifully integrated services. It is a vision for a good life.

A life where people can live at home, with the people and things they love, doing what matters to them, with relationships, somewhere they belong and reasons to get up in the morning.

These things are about much more than public services. But public services can help create the conditions in which a good life is possible. So perhaps the real test of integration isn’t how well our services fit together, but whether they help people live the lives they want to lead.

Integration is worthwhile only if it helps people have more of that life; not simply a more seamless experience of services.

A former boss of mine used to say that good integration is more like a salad than a soup. The ingredients remain distinctive. Each brings something different, but together they create something better.

That matters because we have sometimes confused integration with organisational integration. Pooled budgets, merged teams, shared buildings and delegated functions can all help. But none of them, by themselves, mean someone experiences joined-up support.

The NHS and Adult Social Care bring different things to the table. The NHS brings extraordinary clinical expertise in diagnosing illness, treating it and helping people recover.

Social care starts somewhere slightly different. At its best, it begins with a person: What matters to you? What does a good life look like? What can you do? Who matters to you? What strengths and relationships already exist around you? And only then: what help might you need from us?

We need both.

Genuine integration should value those different perspectives rather than allowing one to be absorbed into the other. Social care should be an equal partner, bringing its own values, expertise and understanding of people and communities.

Starting with someone’s life rather than their needs changes what we see. Someone whose health is deteriorating may need professional support. But what matters most to them might be getting back to the gardening club, collecting a grandchild from school, repairing a relationship, returning to work or simply having somebody to share a cup of tea with.

Those aren’t soft outcomes. They are the things that give people purpose, identity, resilience and belonging. The things that often help keep people well and independent and away from public services.

That is why some of the best social care starts not with which service does this person need? but what does this person want their life to look like, and what resources, relationships and possibilities already exist around them?

Sometimes the answer is a GP, nurse, social worker, occupational therapist, housing officer or care worker.

But sometimes it isn’t a service at all. It is family, friendship, a neighbour, a faith community, a football club, a garden, volunteering, music, work or somewhere you belong.

Good integration needs to make space for both.

That is one of the great opportunities local government brings. Councils sit at the intersection of care, housing, public health, work, money and neighbourhoods, and have relationships with the communities and civic institutions that make places more than collections of public services.

Libraries, community centres, parks, faith groups, sports clubs and voluntary organisations aren’t simply alternative delivery partners. They are part of the fabric in which relationships and belonging grow. They are where a great deal of prevention already happens.

So integration needs to be horizontal as well as vertical. Of course we need better connections between hospitals, primary care, community health and social care. But genuinely preventative care also connects sideways into housing, welfare, employment, communities and the ordinary places and relationships that give our lives meaning.

Otherwise we risk creating beautifully integrated health and care services that still only see part of someone’s life.

And structures only get us so far.

Shared data, aligned geographies, joint teams and budgets can help enormously. But integration happens when a social worker knows who to call in community health; when a housing officer can bring a problem to health and care colleagues; when a voluntary organisation is treated as part of the neighbourhood rather than somewhere to make a referral; and when a care worker notices something has changed and knows somebody will act.

It depends on people knowing each other, trusting each other and having permission to solve problems together. Relationships are part of the infrastructure of good public services, not a nice extra.

Homecare shows what might become possible.

Care workers are in people’s homes every day. They notice the fridge becoming empty, someone becoming less steady, unopened post or a change in mood. But they also know what makes someone laugh, the daughter they haven’t seen, the club they used to attend and the things they would still like to do.

Imagine homecare much more connected into neighbourhood health and community life, with care workers having the time, training, status and relationships to act on what they see and hear.

That doesn’t mean turning care workers into nurses.

Salad, not soup.

It means valuing what someone who knows a person well can contribute alongside the distinctive skills of nurses, therapists and social workers; and the strengths and relationships outside the formal system altogether.

As neighbourhood health develops, perhaps we need some simple tests for integration:

Does it start with the life someone wants to lead rather than the services we already have?

Does it ask what matters to someone, who matters to them and what strengths already exist around them?

Does it help people sustain relationships, purpose, belonging and independence?

Does it connect public services to communities without turning communities into another service?

Does it shift effort towards prevention, home and community?

And, most importantly, is someone’s life better as a result?

There is a huge prize here, including for the NHS. Great social care, strong communities, good housing, friendship, purpose and early help are fundamental to better health as well as better lives. They are how we make the shift from hospital to community and from sickness to prevention real.

So perhaps the next phase of integration doesn’t need to begin with another structural solution.

It could begin with something simpler: start with the life someone wants to lead, understand the people, relationships and place around them, and then ask what contribution services can make to helping that life flourish.

If we get that right, the structures should follow the purpose rather than the other way round.