Phil McCarvill and Richard Humphries on 'Re-Imagining Integrated Care'.
1st July 2022 is the commencement date for Integrated Care Systems (ICS). As the next phase in the development ICSs gets underway, how do we ensure that there is a fundamental shift in how care and support is delivered and experienced? How do we deliver the long-promised shift towards more care and support in people’s homes and communities?
published on 01/07/2022
The starting point for those of us working in health and social care must be what matters and what works for people. Our shared objective must be to provide the conditions for people to access care and support in the right place and at the right time. For most of us, most of the time, that means support that enables us to live in our own homes and communities.
The terms ‘integration’ and ‘integrated care’ are not new, with multiple initiatives over the last five decades to bring health and social care closer together. Sixty years have elapsed since a health minister by the name of Enoch Powell urged local authorities and NHS to work together more closely on a new plan for hospitals and community care. During a House of Lords debate in 1972, Peers noted “integration of services within each community will of itself bring benefit to the patient”, though the concerns of Baroness White were echoed by others: “I think it was the powerful and, some might think, ominous combination of the Treasury and the medical profession which prevented us from achieving this true integration of both the Health and Social Services. At regional level, at least, I would hope that in our lifetime we might see some improvement; but further than that, I think we shall probably all be dead first”.
But it has not always been clear that if integration is the answer, what is the question? Too often integration has involved structural reorganisation and top-down programmes driven by political and managerial priorities with limited engagement of front-line staff and people with experience of care. There has been too much focus on activities and targets associated with pooled budgets, integrated provision and lead commissioning, rather than better outcomes for people. Most independent evaluations have concluded that progress has been mixed, falling well short of original expectations.
The establishment of Integrated Care Systems (ICSs) from 1st July creates new opportunities to re-set the integration agenda. ICSs have to be different, not just another remixing of the alphabet soup of organisational acronyms. They must become more than latter day Area Health Authorities.
There is an abundance of evidence that people want and prefer care to be as close to home as possible. In fact, it seems ludicrous that we are still debating this. The financial and demand pressures on the NHS and social care system are now so great that we cannot afford to squander limited resources on poorly coordinated responses that duplicate effort, incur additional costs, and offer people a poor experience. A new focus on integration means looking beyond organisational silos and focusing instead on the experiences of people with health and care needs, their aspirations and outcomes. For ADASS this means providing the conditions for person-centred joined-up care, in which responses to are designed around the unique needs of individuals and populations rather than the other way round. It is therefore self-evident that care and support must be co-produced with people and communities.
What does this mean in practical terms? Integration should not just be about the NHS and social care. Both are major pieces of the jigsaw but form part of a wider public services family and a wider community infrastructure that includes the voluntary, community and private sectors. ICSs will only be different if they respect what is already there and build from place upwards.
It should take account of everything that has in a place that impacts on outcomes and wider health and wellbeing. For many people integration with the NHS is less important than how well social care works with the benefits system or housing, for example. Integration requires wider partnerships between the NHS and social care with housing, public health, prevention, the criminal justice system, family services and a range of other public services, as well as local voluntary and community sector bodies.
ICSs, and the Health and Care Partnerships within them, are well-placed to take a broad view about what integration means to their places and neighbourhoods and develop a local vision for health and wellbeing and how local public services can work together to achieve this.
This will require a focus on the three key objectives:
- Improving people’s experiences so they can access joined-up, well-coordinated, psychologically informed care and support. They should not have to tell their story over and over again to different professionals, nor should they need navigators to help make their way through an overcomplex system of organisations, rules, and specialisms. Where there are boundaries or gaps, they should not see the joins. People own their own data, and they have the right to control who they share their data with.
- Achieving better outcomes – our combined resources and teams should be focused on enabling people to live good lives at home, for as long as possible. There should be an unstinting focus on reducing the need to use emergency care, crisis support and admissions to long-term care. With a similar emphasis on getting things right first time so that we do not waste precious resources on people returning to hospital because they went home with the wrong support, or repairing the damage caused by a failure to support someone early enough to enable them to live with their condition at home and avoid deterioration that requires more invasive (and more expensive and possibly less effective) responses. The priority for all of us must be good, integrated, collaborative support that enable people to live fulfilling lives. Our shared goal must be to enable everyone to have a good quality of life, no matter what their age or personal circumstance.
- Improving population health – effective integration is not just about what happens to individuals but tackling the underlying factors that fuel the demand for acute hospital and long-term social care. Investing in prevention, public health, mental health, supporting carers, investing in lifetime homes, funding social activities, making homes accessible, and or dementia friendly could make a huge difference to all of our lives. This means prioritising proactive care and investing in a range of community resources that together improve our long-term health and wellbeing.
The development of the next phase of integrated care systems is an opportunity to fundamentally shift our focus towards a rebalanced approach to health, care and wellbeing. At present, the acute hospital sits at the centre of the health and care system, both in terms of the public and politicians’ perceptions of health and social care, and the flow of funding. There is an almost a constant focus on the number of people accessing A&E services and issues relating to discharge, with an almost obsessional focus on beds and ‘flow’. Ironically, part of the solution to the woes of discharge lies not within the walls of the acute hospital, but rather in what happens in people’s homes and communities. For as long as anyone can remember we have lurched from winter crisis to winter crisis and every year the response is the same – more resources to acute hospitals. We need to replace this vicious circle with a virtuous cycle in which primary and community health services, social care and local communities have sufficient investment to help people to live as healthily as possible in their own homes and are admitted to hospital or long-term care only when that is the best option. This means investing in housing-based models of care, physio and occupational therapies, social work capacity, community & District Nursing, intermediate care, home care, rehabilitation, reablement, equipment and adaptations, primary care, end of life care, carers support, and person budgets, with support to help people use them. In addition, we also need to re-prioritise funding for the local voluntary and community sector support which do so much to enable people to remain well, to access high quality information, advice and guidance, and to remain engaged and involved in their local communities.
It is important to acknowledge the barriers to integrated care that have bedevilled previous policy initiatives. Most health care is relatively free at the point of use whereas social care is heavily means-tested and limited to those with the very highest needs. It is far from a universal service like the NHS. Statutory responsibilities for social care sit with 152 separate local councils and most services are provided by over 19,000 independent organisations, Accountability, funding and governance could not be more different from the centrally directed NHS with its direct line of sight to SoS and parliament. In recent years NHS activity and funding has expanded substantially whereas social care has experienced a different funding trajectory and services fewer people than it did a decade ago. Considerable ingenuity and creativity will continue to be demanded of Councils and their NHS partners to find local workarounds to these fundamental national obstacles.
To take forward their local vision of person-centred integrated care, ADASS argues that the immediate priorities of ICSs should include:
- making sure that adult social care is fully engaged in their work, as a gateway into other council functions, and is helping to shape their work and priorities.
- giving equal priority to mental health compared to physical health, given how interrelated issues are.
- avoiding becoming distracted by overly complex governance arrangements at the expense of focusing on outcomes for individuals and communities.
- considering replacing the acute-centric language of ‘out of hospital care’ (implying that hospitals are the centre of the system) with ‘out of home’ care, recognising that most people spend most of their time in their own homes and communities.
- exploring whether we need a new, ring-fenced transformation fund to properly build up home and community capacity.
- prioritising housing-based models of care and the development of strong relationships with councils, housing associations and developers.
- ensuring that acute hospitals, through the new provider collaboratives and in their role as local ‘anchor institutions’, can contribute their expertise and resources to shifting the balance towards home and community.
- creating new opportunities for local systems to share different models of care and shifting away from more centralised approaches, creating space for innovation, and encouraging creativity within local health and care systems that meet the needs of local people rather than adopting models set nationally.
- ensuring that culture of system leadership can be realised despite spiralling demand for care and systematic underfunding across social care and the NHS.
- developing specific objectives to address current challenges such as waiting times, market failure and workforce planning.
- focusing on the public pound, rather than separate NHS and social care budgets, and how resources of all kinds can be aligned to individual and populations. Examples might be: the greater use of personal budgets so individuals can become integrators of their own care and support; bringing together health and social care staff in multi-disciplinary teams; or creating new hybrid job roles across organisations or professional disciplines.
Together we have an opportunity to do something fundamentally different, to shift the balance and resources, and to put people and communities where they belong at the centre of everything we do.