How can health and social care be brought together?
Demand for integration series: Issue 2
The Demand4Integration series takes a new look at the issues facing health and social care, and the necessity of greater integration to not only deliver better outcomes for citizens, better use of resources and better experiences for the workforce but to provide a way of tackling the increasing demand for services while resources are diminishing.
Bringing health and social care closer
Bringing health and social care closer together has been a policy ambition for decades yet it continues to be a challenge. Desired outcomes haven’t always been clear, values and principles haven’t been aligned. While local government’s responsibility for social care has essentially remained the same since the inception of the NHS in 1948, the NHS itself has been through a multitude of organisational changes which have impacted on relationships and responsibilities.
Successes and challenges
A variety of approaches have been taken to achieving integration. There are, however, few examples of integration operating at scale. There has been a focus on structural integration which has delivered few of the intended benefits, depending typically on the leadership and shared values of locally based organisations at the time.
So why is it important to keep trying? Most importantly we keep trying because professionals believe that integration has the potential to improve outcomes for individuals and reduce demand which can often be caused by our services not working well together. By working in more integrated ways the aim should be to create a more coherent personalised response, contributing to what the ADASS calls: ‘A new relationship with individuals, communities and a joined-up care and health system’.
But is integration the only solution to managing demand and improving services? Possibly not, however having a local understanding of what integration means for service users and carers, and working together to understand what can be achieved in a common health and social care system is critical.
Key factors that affect integration
Many issues will impact on success, however there are some key factors that drive the nature and extent of integration and inevitably impact on adult social care. These need to be fully understood, incorporated into strategic planning and well managed:
- Supporting our workforce - the health and social care workforce is the largest in the country. Most staff want to deliver great care, so enabling them to work in ways that deliver the case they would wish for themselves and their families is a key leadership challenge.
- Recognising increasing and more complex need - An understanding of the drivers of demand has to inform strategic planning. People are living longer with more complex conditions and have both health and social care needs. People over 75 are likely to have at least two long term conditions with one in six people over the age of 80 having dementia.
- Acknowledging the huge pressure on the health and care system - 70 percent of the £116 billion NHS budget is spent on people with long-term conditions who occupy 70 percent of hospital beds and take up 50 percent of GP appointments. Local Authority social care budgets are experiencing significant year on year real term reductions. Integration can be a real enabler of change and transformation to support better use of resources.
- Fragmented and complex provider market - a coherent and joint approach to market management is key. 90 percent of social care is provided by around 17,000 different providers in the private and voluntary sector. In the health sector there is a plethora of providers commissioned by different parts of an increasingly fragmented health system. Many care providers are facing increasing costs; threatening their sustainability.
- Significant short term and longer term financial pressures - For social care any additional funding is considered to be too little, too late and continuing budget pressure is forecast for most councils. The ability to levy an additional 2 percent council tax is only likely to benefit more affluent councils and will likely be swallowed up by the impact of the minimum wage. Additional funding for the NHS following the 2015 Spending Review is likely to be absorbed by deficits with 67 percent of health trusts and 87 percent of acute trusts currently predicting deficits in 2016/17. A reduced increase in the NHS budget is likely to impact on services and the ability to achieve requirements like seven day services.
So what can realistically be achieved?
Demand and the requirement to meet increasing need suggests that an integrated response is a logical approach in terms of achieving efficiencies, and laudable in terms of improving people’s experiences. However some immediate questions come to mind which challenge what, how and when this can be achieved.
- How achievable is integration and over what timeframe? Is it about a step change or building on what’s already in place and known to work? Are there different organisational and individual understandings of what integration means?
- Are there really cost savings to be made? For many years most local systems have been trying to achieve better integration and already taken out costs - there may not be much more to go for so is the real gain around quality?
- Is the acute sector really ready to be part of greater systemic integration? Most integration so far has focussed on community health and social care services together with direct engagement with the voluntary sector.
- How will critical operational arrangements manage change? Responsibility (again) has been pushed to local ‘whole systems’ to determine what can be done. Yet tensions are inevitable given NHS top-down performance management in contrast to the local accountability of councils. How robust and flexible is the local provider market? Is the health and social care workforce ready?
- Is strategic leadership strong enough to genuinely lead a strategic ‘place’ based ‘whole system’ approach across a significant geographical area of different communities that are really transformational Of the 44 leads for Sustainability and Transformation Plans almost all are senior health managers. How will the voice of adult social care and its contribution really be understood and recognised?
These are just some of the questions that need to be asked; the response is probably ‘it depends’ - on politics, leadership, strength of partnerships, shared history, and ultimately on people. The issues are complex and in the absence of a simple solution we must continue to ask questions and to explore possibilities that can improve the experiences for people requiring health and social care support.