Ignore the integration naysayers

We know integration delivers better outcomes and better value for money. So as resources in the NHS and in social care get tighter, the population continues to age and service activity increases, integrated provision will be the norm.

But this alone will not deliver the service and financial benefits. Nor will organisational solutions, many of which have been tried in the past and have since been abandoned.

What we need is integrated commissioning – and by this I don’t mean a few joint managerial posts or some pooling of budgets, to create the illusion of integration but in reality paying mere lip service to the concept. I refer to a single or seamless approach – one governance structure, one budget, one group of staff working to a single set of priorities and objectives.

Doomed to fail?

Some will say this is fanciful, doomed to failure, and difficult to achieve due to different financial and governance regimes across the NHS and local government. And anyway, we already do joint commissioning, don’t we?

The Health and Social Care Act and resulting emergence of health and wellbeing boards and clinical commissioning groups presents us with opportunities we have not had before.

In Kingston upon Thames we are seizing the opportunities. Our health and wellbeing board had its first meeting in September 2010 chaired by the leader of the council. Kingston Clinical Commissioning Group is one of the 35 nationally seeking authorisation in the first wave.

These are strong building blocks but not enough.

We believe we are unique in creating the first post which combines the role of accountable officer for the CCG with the statutory director of adult social services for the council.

Hopefully others will follow our lead. Such an appointment gives single top-of-the-office leadership to our commissioning staff and a focus on commissioning for results for all of the client groups across health and social care.

Community ownership

An early example of the significance of this arrangement is the Kingston at Home project. As the name suggests, its objective is to enable our residents to be cared for in their own homes; to reduce our reliance on residential care and hospital beds, and to deliver savings as a result. We have brought together a project team of commissioning managers from health and social care, with GPs from the CCG, managers from social enterprise Your Healthcare (established by Kingston PCT in 2010 to run community health services) and Age Concern Kingston.

Under the proposals we will be transferring council run residential care homes (168 beds) to a local community provider and then working together with the CCG to re-commission and re-provide services across the NHS and social care.

Critical to the success of the project is the business transfer to enable integrated provision.

However, integrating our commissioning so that the services are commissioned together by the CCG and the council is also a prerequisite.

Inevitably, this creates some interesting challenges. The NHS and social care services operate under different governance systems, the former national, the latter local. In a borough like Kingston, localism is fiercely defended.

But finding ways around the financial issues is the biggest challenge and this is not easy, which is why this is not for the faint-hearted. Not only do we have to manage in a system where healthcare is free at the point of delivery and social care is means tested; where the NHS is funded from central taxation and social care partly through local taxation; where business transfer to a social enterprise attracts VAT.

Pooled budget

These are difficult enough, but the really contentious issue is how we deal with increasing costs in social care while savings are achieved in the NHS.

The only sustainable long-term solution is to pool the budget. We therefore need a commitment from the CCG and the council to a set of long-term objectives and joint funding arrangements. Not an agreement which can be torn up when things get difficult but an integral part of the way we do things here.

What if this doesn’t work? Glibly I say it has to, as the consequences of failure are bad for clients and bad for the public purse. But to succeed it needs guts, passion and perseverance.

We don’t have all the answers but we are being ambitious in our approach to tackling the challenges. If you would like to share your experience, we would be very pleased to hear from you at communications@kpct.nhs.uk

David Smith is accountable officer for Kingston CCG and director of health and adult services for the Royal Borough of Kingston upon Thames.