Budget cuts lend impetus to integrating health and social care

This content first appeared in the Guardian:

Across the NHS, social care and government officials are talking about integration. But political and institutional inertia, and public resistance to change, are impeding progress. Back in 2010, progress was being made towards integrated care in New Zealand's Canterbury region. Then came a series of earthquakes, which significantly damaged hospitals' capacity to function. And yet this gave the integrated care initiative more impetus; disaster compelled change.

In Britain the dangers are less violent, but no less real - and yet despite the prospect of another decade of cuts, many staff and most of the public still don't understand what the financial tremors presage.

The Guardian, in partnership with Liverpool city council, hosted a high-level roundtable discussion to debate how to meet this challenge.

The prize from integration is big - more efficient use of diminishing resources and better support for vulnerable people who, too often, languish in hospital beds when they could be at home.

The political rhetoric around integration is hardly new. Health ministers were making almost identical speeches in the 1970s. Now they have declared their intention to have projects in every part of the country by 2015 and an integrated health and social care system in England by 2018. There are to be 14 integration "pioneers".

Austerity is compelling commissioners and providers to bring services together in a way they should have done years ago. Participants in the roundtable variously described the impetus provided by cuts as helpful, welcome and even essential. "If we did not have a burning platform there would be no incentive. The incentive should be our value base around the person and citizen, but our history on that isn't very good, if we're honest."

With the funding cuts forcing change, managers are more willing to take risks, such as moving social care funding from residential homes to reablement. But austerity is also impeding integration because it requires investment in everything from training to IT.

The government's £3.8bn fund for health and social care integration, unveiled in the last spending review, is not entirely welcome. For the NHS, it feels like a spending cut. According to NHS England, it will amount to £10m being taken from the average clinical commissioning group (CCG) budget in 2015-16, when most of the money comes through. So the challenge is not just 'what are we going to integrate?', but 'what are we going to cut to pay for it?'

For local government, the fund offers some relief from unrelenting spending cuts. But the key challenge is the same for both services - to spend the money in a way that will make a long-term difference to the efficiency and effectiveness of local care economies.

Personal budgets

Successful integration is focused not on systems, but on coordinating care and support around an individual. This means putting the voice of the service user at its heart, because seamless coordination between services depends on understanding them from the user's perspective.

Focusing on the individual breaks away from the notion that integration is about getting people in and out of hospital more quickly: "You integrate where people live - in their homes - with housing services, social care, primary care. They visit hospitals rarely." This means not just integrating services, but integrating with the person's life. Personal budgets - an accepted part of the social care landscape, but struggling to get established in the NHS - can play an important role, as well as reducing dependency and cost.

"With personal health budgets, we have talked to people about what will make a difference in their life and made some innovative changes that have brought in the community, so you don't need to pull on social care [as much] because they have their own support network."

Personal budgets move power from institutions to individuals and encourage service providers to listen to what people want. Care services have been too ready to take a paternalistic approach to people's needs, which has crushed independence and pushed up costs.

While individual needs are the starting point for integration, leadership and organisational changes to allow staff to meet those needs are vital: "We need to put in place the foundations to allow our staff to work differently together.

"You need system leadership, workforce engagement around creativity and innovation, and the support mechanisms that will help it to fly. But if you try to do it on the basis of 'what does this mean for our organisations?', you are doomed." Leadership needs to range across the entire system, providing a united vision of the outcomes.

The structural changes involve everything from bringing staff together in the same building to providing a single care record. Reorganising staff does not have to be done in one massive exercise: many places have opted to build integration more slowly, from the bottom up, in different parts of the system.

Integration cannot eliminate boundaries - "there is always a boundary across which we have to work". So leaders need to enable staff to work effectively across those boundaries. This necessitates being clear about everyone's role and responsibilities: "Don't fudge that because, if you do, people fall down the gaps."

The money cannot be fudged either: "System leadership means recognising that savings in one part of the system may well be a burden in another - and there needs to be some movement around that, not just in terms of the £3.8bn, but across 100% of our budgets."

Leadership needs to extend far beyond the boundaries of the NHS and local government to schools, employers, charities, community groups and many other agencies. Care home managers are crucial, ensuring that the rest of the care system is serving the needs of their residents: "From a health service perspective, it sometimes seems that we think if we are speaking to the local authority we've got integration cracked, and it doesn't work like that. It has to go much wider."

Removing obstacles

System leadership also needs to come from the government - and that means removing legal obstacles. The excessive and apparently inflexible intrusion of the Office of Fair Trading into care commissioning needs to be resolved.

Moving between NHS and social services will only feel seamless if users have trust in the professionalism of all staff: "We have to look at making social work much more professional. We cannot take people out of hospital and put them where community care is not regarded as trustworthy." That involves social care responding immediately to people's needs: "Equipment must be there within 30 minutes, not seven days. That is essential to give people confidence."

Integration implies breaking down hierarchies and requires professions to pool and share expertise. For example, nurses are training care home staff to recognise the symptoms of illnesses. It also means supporting other parts of the system. NHS trusts must see social care as more than just a means to get someone out of a hospital bed.

Read the full article on the Guardian website