Local solutions are best for integrated care

Here we go again − the integration merry-go-round moves back into full swing, with bold statements being made by politicians about merging health and social care. Labour sets up an independent commission to consider the integration of health and social care. Backbench MPs are calling for £2bn from the health budget to be used be used to meet the costs of social care for older people.

‘Generally speaking, in any large structural change there are three types of barriers: financial, organisational and cultural’

Meanwhile, council chiefs say social care in England faces a bleak future despite planned changes, as services have been forced into budget cuts. The government’s draft social care and support bill will cap on the costs people face for elderly care, bringing an estimated extra 450,000 people into the state system.

Looking down on this, the man in the moon would be scratching his head wondering why full-on integration of health and social care hasn’t already happened − especially with the explosion in demand from a growing elderly population and the likely impact of degenerative diseases such as dementia doubling over the next two decades.

Something’s got to give. Anyone running a large health organisation must be concerned, particularly when (as with mine) the route to long-term clinical sustainability and quality of secondary and specialist services is highly dependent on a tectonic shift in the provision of “care closer to home” and social care support.

Three barriers

Generally speaking, in any large structural change there are three types of barriers: financial, organisational and cultural. The history of health and social care integration has all three in spades.

Typical financial barriers to success include the costs of setting up and implementing services, making swift returns on investment limited. Cross-charging for delayed discharges has been tried and largely failed as it creates perverse incentives and potentially negative partnership arrangements. Pooled budgets have fared a little better, but they can encourage complex bureaucratic processes involving alignment of governance, legal and financial frameworks.

‘Nimble tailoring of systems to local circumstances is often preferable and more practical than a “one size fits all” system’

Organisational challenges include the task of scoping the service and building systems that incorporate the voluntary sector − and crucially, the hidden contribution and costs of carers. Joining-up the multiple interventions within and between agencies to enable systematic continual assessment and reassessment is also a daunting prospect. Then there are the practical difficulties to be overcome when staff from different professional backgrounds work in multidisciplinary teams.

Cultural differences in perspective among workers providing care can cause significant fragmentation in services aiming at integration. Long-term power imbalances between hospital and community-based services; differences in funding streams across agencies; political accountabilities; organisational structures: all can compromise integration.

Drawing on my own experience of partnership and inter-agency working, success requires some important things to be in place. You must start with good inter-agency relationships. Ideally these are combined with a positive history of joint working, founded on a shared vision backed by clear objectives and setting realistic expectations that take account of local history and context.

Early inclusion of all staff involved, to design the benefits and spot the pitfalls of integration, is essential. Supporting this with comprehensive agreements focusing on final patient and client outcomes will chime with frontline staff.

Road to Damascus

A further feature of successful integration is a single entry point to care. This is central to linking eligibility criteria to assessment, reassessment and referral pathways of care, as well as providing a mechanism for quality assurance and risk management processes.

A flexible approach and nimble tailoring of systems to local circumstances is often preferable and more practical than a mandated “one size fits all” system: an approach almost guaranteed to turn off GPs.

‘Changes in structures and staffing arrangements work best when designed and agreed locally’

Most significant is upfront determination of performance metrics and continuous evaluation. For example, if the intention is to reduce frequent attendees to hospital, it’s important to identify how many occur in a given time period and measure the results to destruction.

Integration and transformational schemes are notoriously difficult to quantify − as the saying goes: if you can’t measure it, you can’t manage it. Equally significant is focused evaluation against a predetermined set of benefits to enable quick enhancement of what works and eradication of what doesn’t.

Back on the broader canvas, it may help us to reflect on the Scottish government’s programme for integrating adult health and social care. To quote deputy first minister Nicola Sturgeon, “These changes represent the radical reform that is badly needed to improve care for older people, and to make better use of the substantial resources that we commit to adult health and social care.”

We are keen to avoid the pitfalls that can accompany centrally directed, large-scale structural reorganisation and staff transfer. Evidence shows changes in structures and staffing arrangements work best when designed and agreed locally, to suit the needs of local patients, service users and carers.

Best not to miss the opportunity this time: there is no scope for another false dawn on the road to Damascus.

Stephen Eames is chief executive at Mid Yorkshire Hospitals Trust