Integrating health and social care

Split roots

Ever since the creation of the National Health Service in 1948, there has been a formal distinction between healthcare, provided free at the point of use by the NHS, and social care, provided on a means-tested basis by local authorities. Historical separations also exist between general and specialist practice, and hence between primary and hospital care, within the NHS itself.

There is a broad consensus that the growing numbers of individuals with long-standing conditions and complex care needs are poorly served by the fragmentation of services that has resulted from this structure.

But the pace of change has been slow: in 1997, then Health Secretary Frank Dobson declared that he wanted to break down the "Berlin Wall" between health and social services; fourteen years later, the report of the NHS Future Forum stated that "we need to move beyond arguing for integration to making it happen".

More recently still, the King's Fund stated that service transformation, including providing more care out of hospitals, "seems very distant".

Change from within

The last Government introduced some statutory duties to promote integrated care and established a £3.8 billion pooled budget for health and social care services (most of which came from within the existing NHS budget).

Some areas have gone far beyond what is required under the law: Torbay, for instance, has pooled budgets for health and social care, and integrated teams of staff, and has been successful in reducing hospital bed occupancy, and in increasing the number of individuals cared for in their own homes.

Elsewhere, achieving greater integration of care services remains a work in progress, and any Government seeking to force the issue may be discouraged by the likely unpopularity of another centrally-directed structural reorganisation of the NHS.

Integration could instead be achieved by change from within. In October 2014, NHS England made its own plans for "breaking down the barriers between family doctors and hospitals, physical and mental health, and health and social care" in its Five Year Forward View.

The plans further address the political and organisational risks of wholesale reorganisation by offering several models through which such integration might be achieved and a degree of local flexibility over which to implement.

These models range from having hospitals run GP surgeries, to having "GP" surgeries employing, for instance, hospital specialists, social workers and mental health practitioners to provide a full range of out-of-hospital care.

In March 2015, it was announced that 29 areas would pilot four different types of care model described in the Forward View.

Leave it to the experts

NHS England was explicit about the proper role for Parliament and Government in its Forward View. In short, they should be providing the resources to support new models of care, without interfering in the details, or attempting to promote a particular approach above others.

Nonetheless, there may be structural and policy barriers to the integration of care services that are amenable to change from the centre. Some of the most widely cited are:

• The mechanism by which healthcare providers are paid for each patient seen or treated ("Payment by Results") encourages hospitals to increase the number of admissions, even when care might be better provided in a different setting: the King's Fund recently described progress in changing the incentives in this mechanism as "painfully slow".
• The inspection and performance framework, which focusses on the quality of care provided by individual organisations, rather than the patient's experience of the system as a whole.
• The objective of increasing choice and competition in the NHS calls for a greater range of providers, operating in competition with each other. This may be at odds with the collaborative approach required to provide well-integrated care.

Money

It is widely acknowledged that integration of care services would improve the quality of care provided to those with chronic conditions. The Department of Health also believes that better management of such conditions could generate £4 billion in savings, largely by reducing the number of costly emergency hospital admissions.

However, the evidence that integration saves money is, according to the Nuffield Trust, "ambivalent", and may in any case initially require extra spending on primary and community services.

The unpalatable prospect of upfront investment for uncertain future savings may limit the scale and pace of transformation.

Health and Social Care Act 2012

• Established Health and Wellbeing Boards in each local authority, with a "duty to encourage integrated working"
• Requires the NHS Commissioning Board and individual Clinical Commissioning Groups to promote integration of health services where this would improve quality or reduce inequalities

Care Act 2014:

• Requires local authorities to promote the integration of health and care provision where this would promote wellbeing, improve quality, or prevent the development of care needs

[…] across the NHS we detect no appetite for a wholesale structural reorganisation. In particular, the tendency over many decades for government repeatedly to tinker with the number and functions of the health authority / primary care trust / clinical commissioning group tier of the NHS needs to stop. There is no 'right' answer as to how these functions are arranged – but there is a wrong answer, and that is to keep changing your mind

15 million – people estimated to be living with one or more chronic long-term health condition in 2012. This is projected to rise by 20% to 18 million by 2025.

Party Lines

• Labour: repeal Health and Social Care Act and integrate services for physical health, mental health and social care
• Conservatives: integrate health and social care through the better care fund
• Greens: repeal Health and Social Care Act and provide free social and health care for all older people
• Liberal democrats: integrate health and social care budget by 2018
• UKIP: integrate health and social care under the control of the NHS