The government needs too reboot the drive for health and social care integration, argues Localis chief executive Liam Booth-Smith. But doing so means facing up to some hard truths.
Twenty years after claiming he would bring it down, Frank Dobson’s Berlin Wall between health and social care remains. As a recent National Audit Office report stated, progress with integrating health and social care has not been what practitioners or policymakers wanted, let alone what politicians promised. With continued downward pressure on social care and NHS funding, and a newly elected government with a mandate for addressing it, is integration an inheritance worth preserving? Today Localis launches a new report arguing in its defence.
Polling for our report shows the public wants the state to take a lead on social care. Around 71% of people think government should be more involved in addressing care needs, and this support cuts across party lines. There’s always been a moral majority behind social care reform, if not an absolute one, which is now finding its voice echoed by the public. Its political salience is on the rise and government must respond. The question is how?
Clearly the forthcoming green paper needs to address the funding question. Ducking it will only irritate the sector and remind people how strapped the system is for cash. Having begrudgingly accepted it the prime minister would be wise to recommit to the Dilnot cap on care costs too. The paper is also an opportunity to reboot the integration agenda, which would be particularly welcome given the walk on part played by local government in the recent update of the NHS Five Year Forward View. But to do this means acknowledging some truths about integration which are hidden in plain sight.
The policy is overburdened by political ambition
The policy is overburdened by political ambition and prey to the conversational sludge know as ‘structural integration’. Take the idea of full integration by 2020. It is almost impossible, if for no other reason than no one can describe what it is. Similarly, achieving financial sustainability through integration. Of the £5.3bn the Better Care Fund made available only £1.7bn went on dedicated transformation programmes. What we can allocate is being used to fill holes in budgets. Central government’s response has not been pull local partners out of this sludge but encourage them to change the way they talk about what it’s like to be stuck in it.
Since 2010 evolutions in policy include, but are not limited to, Clinical Commissioning Group reforms (2011), the Better Care Fund (2013), Integrated Care Pioneers (2013), Vanguards (2014), Sustainability and Transformation Plans (now Partnerships) (2015) and Accountable Care Systems (2017). While only the Health and Social Care Act 2012 was ostensibly about structural change, each has obliquely created new discussions about it.
At its best health and social care integration helps the NHS and local government build services around the patient. This should be the real ambition – more and better person-centred care. Rebooting health and social care integration means Whitehall focusing on the most pressing issues only it can solve and for everything else it should be rigging the policy framework in favour of greater personal choice and control. For example, subject to a positive evaluation of the pilot programmes, promoting Personal Health Budgets – government should legislate to make them mandatory for the most promising specific care pathways. In 2015 12% of CCGs had 50 or more people using a personal health budget, a year and half later that number had more than doubled to 26%.
Beyond this and the strategic leadership politicians should be providing in any case, good integration looks suspiciously like co-ordination. Pragmatic local joining up is key. The dominant trend in health and care independently is to encourage greater independence and agency; integration remains one of the best vehicles to accelerate this process.