Richard Humphries leads us on a walk through the past five years of health and social care – reorganisation; upheaval and cuts. Tracing the roots of a new King’s Fund report back to the Barker Commission, he points us firmly on a clear and concise route to devolved integration.
SEASONED SOCIAL CARE leaders will need no reminding of the NHS’s propensity for serial reorganisation. Andrew Lansley’s shake-up, enacted in the Health and Social Care Act 2012 and famously described by former NHS England boss David Nicholson as “so big you could probably see it from space” – was intended to ‘liberate’ the NHS from top-down control and reduce bureaucracy. Two years later space travel is not required to see the consequences, write Richard Humphries.
Changing demography and patterns of illness mean that more of us – including younger people with disabilities – are living longer with a mixture of needs that defy organisational boundaries and budgets. Integrated care is more important than ever. But ensuring individuals experience has never been more difficult, with commissioning responsibilities for different pieces of the service jigsaw now scattered across approaching 400 separate bodies in the NHS, local government and the NHS.
This makes it so much harder to join-up health and social care and address the other major fault lines between primary and secondary health care and between physical health and mental health services. No-one starting from scratch would design a commissioning architecture so complex that, rather like the peace of God it passeth all understanding.
So it was not surprising that the Barker Commission’s headline recommendation was to establish a single ring-fenced budget for all NHS and social care services overseen by a single local commissioner. Our subsequent engagement with stakeholders – including ADASS – has reflected general support for the direction of the Barker proposals but massive anxiety about the prospect of further organisational change to achieve them. This is entirely understandable – the evidence that structural changes alone does not produce better outcomes is unequivocal.
So in our latest report – Options for integrated commissioning: beyond Barker - we look at how we could achieve a more coherent and joined-up set of local commissioning arrangements while avoiding the traumas of yet another top-down reorganisation.
The starting point should be to focus on the outcomes that well-designed integrated care should aim to achieve everywhere through a single, nationally agreed outcomes framework. A mandatory requirement should then be placed on all local authorities and CCGs to demonstrate how, by the end of the next parliament, those outcomes would be achieved locally through a single commissioning function for their local population.
This should be expressed in a local integration programme that sets out a timetable to move towards a single integrated budget which should include, as a minimum, spending on adult social care, community health, public health, primary care and mental health services and defined acute services (which should be agreed on a service-by-service basis as Scotland have done). The organisational model by which this is achieved should be developed and agreed locally – the report sets out some options - so that by 2020 at the very latest there will be a single local commissioning function, with a single integrated budget, in place in all parts of the country. The report describes some places who have already begun this journey.
This approach has some key advantages. It goes with the grain of the direction of travel set out by ADASS in its ‘Distinctive, Valued, Personal – Why Social Care matters’ discussion document as well as the NHS England Five Year Forward View. It focuses on what local arrangements will best suit local needs rather than impose a singe national template. It does not stop health and wellbeing boards, in places where they are working well, to evolve into the single commissioner – though this would need some radical changes. It would simplify the proliferation of current integration programmes – pioneers, vanguards, Better Care Fund and personal commissioning pilots – into one plan for one place, and one set of consistent oversight and support arrangements.
Like Barker, we accept that integrated commissioning will not of itself be sufficient to overcome the deeper dividing lines between health and social care - especially funding. The need to secure adequate sustainable funding of both health and social care– facing a combined funding gap of at least £12 billion by 2020 – underlines the need for a single combined spending review process and settlement for the NHS, social care and public health. The Department of Health would become the primary department of state responsible for negotiating and agreeing the settlement for the single integrated budget and allocating it to local areas. Changes will be needed on the provider side too.
As the separate policy trajectories of integration and devolution begin to converge, the full merger of health and social care budgets would be a major milestone towards the creation of single place-based public service budgets on a much bigger scale. Local authority social care leaders are well positioned to be in the vanguard of these developments in their own areas. This will be risky, but the risks of inaction are greater still.
Assistant Director, Policy
The King's Fund