Coronavirus is a true test of integration

From the moment sustainability and transformation plans were launched in 2016, there has been legitimate concern about how far social care, the community and third sector, and independent sector providers would really be embedded.

It might be it takes this coronavirus crisis to really answer how integrated health and care systems can truly become.

Social care

One integrated care system leader told me transformation work that has been in the works for 18 months has been resolved in a week. The source said: “Integrated care partnerships which were just in early discussion phases are now working efficiently together to help empty hospitals. There has been instant mutual aid between trusts over [protective equipment], where before some of those organisations wouldn’t have shared.”

The ICS boss added a memorandum of understanding about sharing workforce had also been signed in the week, when it had been under debate for more than a year. “Suddenly all those people who insisted they had to be in the room for these conversations [thus delaying the process] are happy to be represented by other people.”

But, for all the benefits, I and colleagues are also hearing concerns that working together in social and community care has often remained harder.

One commentator on an HSJ story said: “I’m trying really hard to empathise with community and social care staff…. the world has changed dramatically for us all. But faced with trying to discharge 90 medically fit patients from two sites by Friday, it’s as if they’ve been deaf to the emergency and the government instructions.”

But one senior council official told me that from their side: “The lack of parity of social work with the NHS in the public’s and politician’s eyes is surprisingly deep still.”

It is perhaps unsurprising that this week the Local Government Association issued a plea to ask the government to introduce the same measures to get retired social care workers back into the work place as it has already for retired medics.

While PPE supplies now appear to be getting into care and nursing homes, one of the concerns raised to HSJ — PPE for domiciliary care workers — has barely been addressed despite the fact they are going in and out of older and disabled people’s homes, many of whom are part of the 1.5 million group of people told to never go out for the next 12 weeks due to their severe underlying health problems.

But the days when social care being part of joint system working would appear to be over. Coming out of this crisis people, from trust chief execs down, will have learned first hand why true integration with social care is needed.

Community health

Reading through the government’s plans to massively reduce delayed transfers of care to free up beds, there is another massive challenge on the horizon for community health workers. While trusts are rightly focused on reducing bed occupancy ahead of the coronavirus tsunami, the bar has also been set very low as to when patients are ready to be discharged.

NHS England’s guidance said that when assessing if a patient was ready to go home, doctors were not to ask if the patient is “medically fit” or “back to baseline” but instead if they were “medically optimised”. It acknowledges this will require patients to receive ambulatory heart failure treatment, intravenous antibiotics and oxygen all at home.

Government has at last turned on the spending taps to create this vastly expanded free care system — funded via both local government and directly through the NHS — removing money as the barrier; but there are others.

Community health teams will need to be rapidly trained to be able to cope with the increased case complexity that will now be dealt within the community.

When asked if they were ready for the surge in community care, one ICS leader said: “No, but we will, because we have to be. It will take training though and that is the risk. How do you set up a training programme and rapidly upskill people to do things like home IVs?”

This leader added Health Education England had been surprisingly quiet on the issue and asked for some “help and direction from them”; perhaps HEE will step up this week.

Independent providers

It seems too that the world has changed for how STPs and ICSs deal with private providers. This week the government asked NHSE to take on the power to commissioning independent care providers (as well as other services), in part because having bought up almost the entire private sector capacity and capability there seems little point in clinical commissioning groups acting as the financial middleman.

However in a new development, NHS England is now asking for a “lead acute NHS trust or STP/ICS [to] take responsibility for coordination between the [independent sector] provider(s) and other NHS providers across the region and form an ‘IS coordination network’”.

“The IS coordination network should be led by the lead acute trust or STP/ICS but include representatives from other NHS acute trusts in the network as well as the IS sites.”

As soon as NHSE made a grab for these CCGs powers, many people told me that commissioners would be unlikely to get them back in future, with much of localised and day-to-day purchasing tasks being phased out regardless.

The above new set up will certainly act as a test bed as to how a system-directed approach like this could work in the long term. It will be attractive to many ICSs too, as it may point towards resolving how they can maintain patient choice and competition in a world where NHS trusts are increasingly working together. Separating independent providers from the commissioning powers of an ICS might create enough distance to refute any concerns over conflict of interest when contracts are given out to local trusts.

The NHS and linked services have routinely struggled to integrate care across sectors, with most successes to date focused on specific care pathways or conditions, such as diabetes. And if it can’t be done during a national crisis, it is unlikely to be achievable in any meaningful way during “peacetime”.