Integrating health and social care – taking stock of the options and moving forward
With all the noise surrounding the need to integrate health and social care, there is a risk that it will drown out the very essence of what integrated care is actually intended to do: improve the patient experience. That is not to say that greater value for money cannot be achieved through more efficient and streamlined service delivery, but if the patient’s experience of receiving health and social care services has not improved, then care has not been integrated.
The Social Market Foundation (SMF) published a report in March this year, “Putting Patients in Charge: The Future of Health and Social Care”. SMF’s report helpfully reiterates that integrated care is about people centric care. This includes preventing ill-health and the effective management of care crises. With lack of funding for NHS services being a perennial issue, compounded by an aging population and an increasing number of people living with multiple chronic conditions, the need for action has never been greater.
SMF’s report makes a number of recommendations, but two of the key ones are:
The SMF argue that integration requires public accountability, funding and commissioning to rest in one place.
Strangely, the Health and Social Care Act 2012 fragmented the commissioning structure by abolishing PCTs and replacing them with NHS England and CCGs. When local authorities are added into the mix it is clear that this is not an ideal starting point for commissioning integrated care.
The 2012 Act explicitly promotes joint working between health and social care, principally through the establishment of Health and Wellbeing Boards (HWBs), which oversee integrated services in their area. The overall purpose of HWBs is to bring together bodies from the NHS, public health and local government, including patient representatives, to plan how best to meet local health and social care needs.
The full potential of HWBs is yet to be realised, but, under current legislative arrangements, they are best placed to commission integrated care, as they have the ideal mix of clinicians, democratically elected local authority representatives, and a patient voice through HealthWatch.
Not only that, but as the commissioning of integrated care necessitates the commissioning of primary and secondary care services, HWBs would offer a neat solution to the conflict of interest issues surrounding CCGs commissioning primary care services.
Interestingly, in its February 2014 report on public expenditure on health and social care, the House of Commons Health Committee stated: “We continue to believe that fragmented commissioning structures significantly inhibit the growth of truly integrated services… HWBs should be encouraged to develop their role to provide an integrated commissioners’ view of the transformative change...”
However, expanding the role of HWBs will not offer a straightforward solution. There remain a number of hurdles to overcome, not least that HWBs do not have the authority to commission services. Even when HWBs act as a forum for integrated commissioning, obstacles are still plentiful. For example, when commissioning NHS-funded services, including those commissioned as part of an integrated care pathway with a local authority, the NHS Standard Contract must be used. Whilst this is a perfectly good contract for the commissioning of acute care, it is questionable whether it will appropriate for engaging providers to deliver social care services and NHS services both in the community and in hospitals. While problems such as this are not insurmountable, they will need to be carefully considered and addressed.
SMF argue that there is little sense in treating health and social care needs differently. If one takes a step-back, it is indeed peculiar that NHS-funded services are free at the point of access, whilst social services are means tested with a potential for an unlimited contribution from patients. As the SMF point out, why should there be a natural lottery where, for example, a patient will receive treatment of a broken leg for free but dementia care may incur costs into the thousands of pounds?
If HWBs were to be given the purse strings for commissioning health and social care services (and the authority), it is highly unlikely that social services would become free at the point of access, but rather, NHS services may become means-tested. At first sight this suggestion appears repugnant. However, if establishing a health and social care service today, it is unlikely that the disparity between health and social care funding would ever be considered.
A shift in mind-set and approach is needed. As the SMF suggest, perhaps it is time for the new government to consider establishing a NHSCS (National Health and Social Care Services).
Originally published on the National Health Executive website.