Let's take integrated care from rhetoric to reality

I’ve often spoken about the need to join up health and social care commissioning, in HSJ and more recently at the NHS Confederation conference and the Commissioning Show. In my position as a clinical commissioning group chief officer and director of health and adult services for a local authority, it is perhaps not surprising that this is my vision, not least because my joint role means we are in the ideal position to achieve it.

‘Our strategy is starting to work on the ground and we are gathering evidence of how this is improving the lives of our residents’

However, there comes a time when we need to move from rhetoric to real action. So what have we been doing to achieve this joined up vision and what learning can we share?

It is almost a year since Kingston launched its joint “Kingston @ Home” strategy to support combined health and social care services to support more people to live independently when they want to.

During the year we have successfully transferred £5m of adult social care services to our social enterprise provider of community health services. We have put in place a single point of access for patients where they would previously have needed to contact different teams. We have closed one of our council run residential care homes as a result of caring for more people in their own homes.

Our strategy is starting to work on the ground and we are gathering increased evidence of how this is improving the lives of our residents. We know we have much more to do to ensure services are really connected and personalised but we can see that integrating health and adult social care is starting to deliver.

Joined up commissioning

However, this is not enough. Unless we put in the same amount of effort to join up the way we commission services, at best this will slow down the innovation we need our providers to deliver, at worst it will stifle them. Working in a London borough council with a co-terminous CCG, we should have the ingredients to join up our commissioning.

Certainly the relationships between the council and the CCG are strong and there is a shared vision that we must fully integrate our commissioning. My vision is of a system where we have one governance structure; one budget; one team of staff who commission across health and social care. Our challenge is to turn this into reality and to do it quickly. We cannot take years to do this.

‘The sceptics are not going to be convinced just because I tell them this is a good idea’

At our last health and wellbeing board meeting in April, a report was approved that committed to putting some meat on the bones to establish a truly joint health and social care structure, and we are now in the process of investigating how it will work and what it will mean. We expect to make significant progress on this over the coming months.

Changes of this type call for brave leaders across health and social care, who are prepared to invest their time and energy to make it happen. But I also believe that there needs to be a solid business case that clearly demonstrates that integration as we describe it will deliver benefits for patients and financial benefits.

The evidence base for integration is not in one place, so it is difficult to find concrete examples of this delivering in practice. The sceptics are not going to be convinced just because I tell them this is a good idea, despite my fantastic persuasive ability.

Time to deliver

There are many barriers in the way but anything that involves money is a significant problem, and maybe the biggest barrier of all. I accept that the different funding systems for health and social care don’t help but there is little we can do on that score.

However, continuing to operate different payment systems across health and social care will get in the way of true integration. While payment by results does not incentivise NHS providers to manage costs down, at least this is better than for some community services and social care where payment mechanisms are almost non-existent.

We have to find a payment mechanism that incentivises providers to improve outcomes and quality while at the same time keeping costs down − but in such a way that it does not shift all the financial risk in their direction. It is not in my interest as a commissioner to bankrupt my providers.

We believe we have some learning to share but we are also keen to learn from others. We still have a way to go but we do have a clear goal and are making progress − now we just need to make sure we deliver.

David Smith is chief officer at Kingston Clinical Commissioning Group and director of health and adult services at Royal Borough of Kingston upon Thames Council, communications@kpct.nhs.uk