Health and care: beyond simply rearranging the furniture

health and care

For years now, policymakers and health sector stakeholders have pushed for a joined-up system of heath and care. Yet, despite repeated legislative endeavours, there is a worrying lack of clarity as to what successful integration truly looks like.

Perhaps nowhere has this lack of progress been more acutely felt than in the care sector. Concurrent challenges of unprecedented demand, high staff turnover and poor levels of recruitment (in no small part thanks to Brexit) has left the sector on its knees. Then there is the not so small matter of a global pandemic – which cast a spotlight on the stark reality that is the state of England’s health and care system.

Amid widespread agreement that integrating the country’s health and care system drive improvements to patient outcomes;, it is hard to escape underlying feelings of scepticism, particularly, within the care sector, when it comes to the latest attempt at reforming the UK’s health and care system. This sentiment is driven, in part, by the daunting myriad of challenges facing the healthcare sector, creating anxiety amongst care providers that they will get receive support until the NHS can address issues such as the ominous elective care backlog.

The government’s answer? More policy. With its upcoming white paper on social care integration, Whitehall will seek to clarify the outstanding questions and (we hope) finally begin the transition from policy to practice.

To help crystalise these challenges and begin to turn policy into practice, Public Policy Projects (PPP) hosted an evidence session in January 2022 entitled: Integrating Health and Social Care: A National Care Service, as part of its report series: The Future of Social Care. Senior cross-sector stakeholders in social care were convened to highlight the most urgent issues regarding social care, as well as put forward solutions to help progress them within an Integrated Care System (ICS) context.

Unsurprisingly, a recurring theme was enhancing localised decision making within a nationally driven policy agenda –- a balance that has yet to be struck. ICSs must have the autonomy and flexibility to plan and deliver care strategies accordingaccording to the needs of their populations and this unlikely to be achieved through central control.

While the government has insisted that the bill aims to enhance local autonomy, there is considerable scepticism as to whether Whitehall is truly serious about allowing a ‘thousand flowers to bloom’ outside of its control. We may never find a nationally agreed upon metric to accurately and consistently measure the success of integration and there is still worrying lack of clarity as toon what this new “structural cohesion” is supposed to achieve. The fear is that supposed government enthusiasm for integration may turn into frustration when localised decision making inevitably delivers something different than what was exactly envisaged from the centre.

Rearranging the furniture

As far as the care sector is concerned, nothing less than wholesale service transformation will do. ICSs cannot simply be another attempt in a long line of efforts at just ‘moving the furniture’, or simply creating a structural change to hide a desperately under resourced and overwhelmed care sector. Funding disparities between different care settings must be corrected and the ICS agenda must come with new, brave and bold ways of delivering care.

Whatever the debate around integration, the lived experience of the people who are at the receiving end of services must remain central to service reform. The ‘holy grail’ of integration for the care sector is an assurance that people can receive care and remain safe, with dignity, within their own homes for as long as possible.

While care providers share these aspirations, the geographical separation of England’s 17,000 care homes makes local community collaboration difficult. The latest policy around integration does include some specific points to encourage local collaboration. Integrated care boards (ICBs) and local authorities are required to establish integrated care partnerships with the responsibility of convening a broader partnership and producing an integrated care strategy.

In striving for local collaboration, ICBs need not reinvent the wheel. The foundations for health and care partnerships were put in place with establishment health and wellbeing boards, committees tasked with addressing with improving the health of the local population by advancing service integration. The boards were classified as a ‘partnership forums’ with limited formal powers rather than an executive body, and therefore they have had limited impact. However, many stakeholders (particularly from local authorities) believe that the local knowledge of these boards can be used as the ‘glue’ for ICBs to build place-based partnerships and address health inequality in locality.

The money problem

The NHS has been faced with the most challenging period of service provision since its inception – convincing stakeholders to shift resources away from the acute sector will not be easy. But integrated care must come with a rebalancing of the books, or it will be doomed to fail. Can the care sector rely on the goodwill of policy makers and providers to share resources? Or will these sentiments and shared aspirations for place-based care be superseded by growing political pressure to meet targets and reduce hospital wait times?

If any lesson isto be learnt from, it is that the sector cannot consider health crisis under a purely acute sector bracket. If service challenges and the ICS model designed to address them become subsumed under just ‘health’, there is a risk that funding support will be allocated on an acute sector basis – essentially sucking money from the rest of the system. ICSs cannot somehow become an adjunct of the NHS. It’s got to be a completely reformed and reviewed model.

Crucial to securing shared investment across the different facets of an ICS will be the establishment of a shared strategic vision. Strategy drives investment and if systems get this right and allow ICBs to be the guardians of these visions, systems will drive investment.

A theme that has consistently appeared throughout PPP’s The Future of Social Care series so far is the need for patience. The government must give ICSs the time and autonomy they need, while also ensuring that appropriate funding gets to community care. PPP will continue to hold such discussions with key stakeholders to lead the integrated care agenda.

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