By Alison Moore | 1 March 2012
The Health and Social Care Bill is meant to help clinicians provide patients with better integrated local care services. But a growing chorus of critics think it will have the opposite effect. Who’s right?
Integrated care has become the Holy Grail for the NHS. It remains elusive but everyone believes in its power to resolve the looming problems of millions of babyboomers with long-term health conditions.
Almost all commentators believe that the growth in numbers of people who are frail and elderly or have chronic conditions will put the health service under serious pressure in the next few decades. The traditional model of hospital care will be hard to sustain financially and an alternative approach will be needed, one that keeps more people in their own homes with enhanced support.
But the fundamental divide between the care provided by hospitals and the social care provided by local authorities remains. This is ‘now a major cause of inefficiency and service breakdown’, the Commons health select committee stated starkly in its January report on NHS spending. The MPs added that greater integration was ‘the only realistic option… capable of delivering service change on the scale required’.
By February, in a report on social care, the MPs had concluded: ‘Although the government has signed up to the idea of integration, little action has taken place to date. The committee does not believe the proposals in the [Health and Social Care] Bill will simplify this process.’
With the NHS already in a state of structural upheaval as the controversial Bill completes its fraught passage through Parliament, how is integration going to be achieved?
In theory, integration is simple. Responsibility for many chronic conditions should be shifted to primary and community services, reducing emergency admissions and ensuring hospital care is largely planned and a last resort. Councils would provide all the necessary support to allow people to remain at home. From the patient’s point of view, the service should feel seamless as information would be shared between the two sectors and ideally a ‘care management’ approach adopted. This would mean professionals from health and social care jointly evaluate each patient’s evolving needs and implement a comprehensive care plan.
In practice, although integrated care has been talked about for decades, progress on introducing it has been slow and often piecemeal. A number of pilots have been running since 2009 but they often concentrate on small groups or geographical areas.
The health Bill itself contained few references to integration on its first outing, focusing on competition and services to be delivered by ‘any willing provider’. Far from integrating services, it was widely attacked as potentially leading to fragmentation. Critics claimed that organisations would chase patients to boost income, regardless of where they would be best or most economically treated.
Now, however, the government is playing down the competition angle and emphasising integration and the Bill has been revised to put a greater focus on this. A Department of Health spokesman told Public Finance: ‘Integrated care should be the norm. That’s why we asked the NHS Future Forum to specifically work on the issue. Our ambition for the NHS and social care is a simple one – to achieve better results for people and carers. So our priority is to orientate the whole system around patients, service users and carers through our Outcomes Framework.’
Last year, the Future Forum, chaired by Professor Steve Field, stressed the importance of integration in improving care for patients but argued there was ‘no silver bullet’ to deliver it. Instead of a centrally prescribed model, it should be made easier for local leaders to work together, it concluded.
Many commentators are not convinced that the Bill, which has managed to alienate most of the medical establishment, will make a positive difference to the integration agenda. The British Medical Journal, among others, has claimed that care integration is ‘ill defined’ in the draft legislation and ‘lacks any meaningful incentives to encourage its adoption’.
Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, says a proper ‘public bureaucracy’ is needed to drive an integrated system.
There is also widespread concern that the structural disruption caused by the other changes in the Bill will hinder progress. The NHS Confederation says that although promotion of integration is included in the draft legislation, the ‘creation of new bodies and the division of responsibilities for various services risks fragmenting care more rather than less’. Changes have already taken place, with primary care trusts largely replaced by PCT clusters, which will eventually be superseded by clinical commissioning groups with different boundaries. PCTs’ community services have been separated from their commissioning side and are now either running independently, have been taken over by other organisations or have become social enterprises.
The result has been disruption to long-established relationships. Where integrated care has been successful it has often been due to good local relationships and shared borders between social services departments and the local health service. For example, Torbay Care Trust in Devon – one of the oldest examples of an integrated approach – is said by the King’s Fund to demonstrate ‘the importance of organisational stability and continuity of leadership’.
On the more positive side, late revisions to the Bill have strengthened the role of health and wellbeing boards and beefed up regulator Monitor’s statutory power to impose integration of services as a condition on providers. The government has, however, stopped short of any structural integration.
Peter Hay, president of the Association of Directors of Adult Social Services, believes the health and wellbeing boards will be the main players in holding the health service to account and pushing for improvement and integration. However, they will not be given powers to turn down commissioning plans that fail to address this issue sufficiently.
Progress on reform of social care funding – an important part of the picture – has also been slow. The February health select committee report called for joint commissioning to be backed up by a single accounting officer and outcomes framework. Committee chair Stephen Dorell said this would ‘make it easier to move money around the local health, housing and social care systems’.
King’s Fund senior fellow Nick Goodwin also believes the Bill will not do enough to bring things forward and he wants more tangible action from the Department of Health. One is the creation of incentives to help people work together. For example, the government is developing some changes to the payment-by-results hospital funding tariffs to support entire ‘care pathways’ rather than one-off ‘episodes of acute admissions’.
Another issue is governance, because health and social services are often judged on and asked to achieve different things. They also work to different timescales – integrated care might need committed funds over a period of years.
Then there is the possibility that trusts’ role might change and services or whole hospitals close. Lack of vision in this sector could inhibit developments, Goodwin says. But he is heartened that Monitor is thinking about its role in providing incentives for integrated care rather than simply encouraging competition.
Monitor chair David Bennett recently said that the watchdog would have a major role in driving integration, but that commissioners would be the main driver and that providers needed to produce integrated solutions.
Much of what could be done does not require legislative change, Goodwin argues. The powers to commission integrated care and to devolve or share budgets with other organisations across health and social care are in large part already in place. ‘We are lacking oomph in taking forward the integrated care agenda,’ he says.
There are other questions not addressed by the Bill, such as the two funding regimes involved – means-tested social care and free NHS care. People being supported to stay at home might end up paying for elements of care that would be provided free in hospital unless this eligibility hurdle is overcome (see box below).
Councils have been looking for solutions but often around monitoring or preventative services. For example, Birmingham City Council and the local PCT are spending £4m a year over three years to put telehealth equipment into people’s homes. That is done without means-testing.
Even with means-testing, councils are struggling to provide care to all who need it. Over the past few years, it has been restricted to people whose needs are at least ‘substantial’.
Effective integrated care might require much more social care investment – and at the moment there seems little choice but for NHS money to be spent on aspects of care that might traditionally be seen as social or personal care. A report from Age Concern highlighted a £500m care spending gap that has developed since the coalition government came to power.
Squeezed social care budgets are a danger to integration. The health select committee was told in January that even in Torbay there was a danger of retreating back into a ‘silo mentality’ because of cuts in social care funding.
In some cases, organisations might end up being given a set pot of money to provide care for a defined group or for those following a certain care pathway – and freedom to spend it as they think fit. This sounds similar to the health care management and managed care organisations in the US. Kaiser Permanente, for example, stresses preventative care and co-ordination of care between providers.
For many though, the main question will be whether integrated care will put the NHS in a better position to meet the ‘Nicholson challenge’ and find the £20bn it is required to save by 2015. The evidence is not clear-cut that integrated care always reduces costs, says Goodwin.
In some cases, although people have been given support to remain at home, this has not reduced admission costs and bed use sufficiently to offset the additional cost. This might be because people are being picked up too late – when they already require hospital admissions and little can be done to keep them at home long-term.
Goodwin believes integrated care can reduce costs but to do so the right groups of patients need to be identified, access to care needs to be round the clock and all the pieces of the care jigsaw need to be in place. Introducing just one or two elements won’t produce the desired result.
He suggests that a relatively small number of people might need the intensive support and case management approach – but as they will be disproportionate users of health services there is scope for considerable savings. ‘Targeting the right people is very important to have a cost-effective result,’ he says. ‘I don’t think the system is quite intelligent enough to do that.’
Time is also needed: it took the Torbay Care Trust 12 years to make all the changes it needed. That makes integrated care something that needs to sit outside politics. A tall order in a climate of bitter controversy over NHS reforms and huge pressure to make cost savings.
The Health and Social Care Bill is meant to help clinicians provide patients with better integrated local care services. But a growing chorus of critics think it will have the opposite effect. Who’s right?
Integrated care has become the Holy Grail for the NHS. It remains elusive but everyone believes in its power to resolve the looming problems of millions of babyboomers with long-term health conditions.Almost all commentators believe that the growth in numbers of people who are frail and elderly or have chronic conditions will put the health service under serious pressure in the next few decades. The traditional model of hospital care will be hard to sustain financially and an alternative approach will be needed, one that keeps more people in their own homes with enhanced support.
But the fundamental divide between the care provided by hospitals and the social care provided by local authorities remains. This is ‘now a major cause of inefficiency and service breakdown’, the Commons health select committee stated starkly in its January report on NHS spending. The MPs added that greater integration was ‘the only realistic option… capable of delivering service change on the scale required’.
By February, in a report on social care, the MPs had concluded: ‘Although the government has signed up to the idea of integration, little action has taken place to date. The committee does not believe the proposals in the [Health and Social Care] Bill will simplify this process.’
With the NHS already in a state of structural upheaval as the controversial Bill completes its fraught passage through Parliament, how is integration going to be achieved?
In theory, integration is simple. Responsibility for many chronic conditions should be shifted to primary and community services, reducing emergency admissions and ensuring hospital care is largely planned and a last resort. Councils would provide all the necessary support to allow people to remain at home. From the patient’s point of view, the service should feel seamless as information would be shared between the two sectors and ideally a ‘care management’ approach adopted. This would mean professionals from health and social care jointly evaluate each patient’s evolving needs and implement a comprehensive care plan.
In practice, although integrated care has been talked about for decades, progress on introducing it has been slow and often piecemeal. A number of pilots have been running since 2009 but they often concentrate on small groups or geographical areas.
The health Bill itself contained few references to integration on its first outing, focusing on competition and services to be delivered by ‘any willing provider’. Far from integrating services, it was widely attacked as potentially leading to fragmentation. Critics claimed that organisations would chase patients to boost income, regardless of where they would be best or most economically treated.
Now, however, the government is playing down the competition angle and emphasising integration and the Bill has been revised to put a greater focus on this. A Department of Health spokesman told Public Finance: ‘Integrated care should be the norm. That’s why we asked the NHS Future Forum to specifically work on the issue. Our ambition for the NHS and social care is a simple one – to achieve better results for people and carers. So our priority is to orientate the whole system around patients, service users and carers through our Outcomes Framework.’
Last year, the Future Forum, chaired by Professor Steve Field, stressed the importance of integration in improving care for patients but argued there was ‘no silver bullet’ to deliver it. Instead of a centrally prescribed model, it should be made easier for local leaders to work together, it concluded.
Many commentators are not convinced that the Bill, which has managed to alienate most of the medical establishment, will make a positive difference to the integration agenda. The British Medical Journal, among others, has claimed that care integration is ‘ill defined’ in the draft legislation and ‘lacks any meaningful incentives to encourage its adoption’.
Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, says a proper ‘public bureaucracy’ is needed to drive an integrated system.
There is also widespread concern that the structural disruption caused by the other changes in the Bill will hinder progress. The NHS Confederation says that although promotion of integration is included in the draft legislation, the ‘creation of new bodies and the division of responsibilities for various services risks fragmenting care more rather than less’. Changes have already taken place, with primary care trusts largely replaced by PCT clusters, which will eventually be superseded by clinical commissioning groups with different boundaries. PCTs’ community services have been separated from their commissioning side and are now either running independently, have been taken over by other organisations or have become social enterprises.
The result has been disruption to long-established relationships. Where integrated care has been successful it has often been due to good local relationships and shared borders between social services departments and the local health service. For example, Torbay Care Trust in Devon – one of the oldest examples of an integrated approach – is said by the King’s Fund to demonstrate ‘the importance of organisational stability and continuity of leadership’.
On the more positive side, late revisions to the Bill have strengthened the role of health and wellbeing boards and beefed up regulator Monitor’s statutory power to impose integration of services as a condition on providers. The government has, however, stopped short of any structural integration.
Peter Hay, president of the Association of Directors of Adult Social Services, believes the health and wellbeing boards will be the main players in holding the health service to account and pushing for improvement and integration. However, they will not be given powers to turn down commissioning plans that fail to address this issue sufficiently.
Progress on reform of social care funding – an important part of the picture – has also been slow. The February health select committee report called for joint commissioning to be backed up by a single accounting officer and outcomes framework. Committee chair Stephen Dorell said this would ‘make it easier to move money around the local health, housing and social care systems’.
King’s Fund senior fellow Nick Goodwin also believes the Bill will not do enough to bring things forward and he wants more tangible action from the Department of Health. One is the creation of incentives to help people work together. For example, the government is developing some changes to the payment-by-results hospital funding tariffs to support entire ‘care pathways’ rather than one-off ‘episodes of acute admissions’.
Another issue is governance, because health and social services are often judged on and asked to achieve different things. They also work to different timescales – integrated care might need committed funds over a period of years.
Then there is the possibility that trusts’ role might change and services or whole hospitals close. Lack of vision in this sector could inhibit developments, Goodwin says. But he is heartened that Monitor is thinking about its role in providing incentives for integrated care rather than simply encouraging competition.
Monitor chair David Bennett recently said that the watchdog would have a major role in driving integration, but that commissioners would be the main driver and that providers needed to produce integrated solutions.
Much of what could be done does not require legislative change, Goodwin argues. The powers to commission integrated care and to devolve or share budgets with other organisations across health and social care are in large part already in place. ‘We are lacking oomph in taking forward the integrated care agenda,’ he says.
There are other questions not addressed by the Bill, such as the two funding regimes involved – means-tested social care and free NHS care. People being supported to stay at home might end up paying for elements of care that would be provided free in hospital unless this eligibility hurdle is overcome (see box below).
Councils have been looking for solutions but often around monitoring or preventative services. For example, Birmingham City Council and the local PCT are spending £4m a year over three years to put telehealth equipment into people’s homes. That is done without means-testing.
Even with means-testing, councils are struggling to provide care to all who need it. Over the past few years, it has been restricted to people whose needs are at least ‘substantial’.
Effective integrated care might require much more social care investment – and at the moment there seems little choice but for NHS money to be spent on aspects of care that might traditionally be seen as social or personal care. A report from Age Concern highlighted a £500m care spending gap that has developed since the coalition government came to power.
Squeezed social care budgets are a danger to integration. The health select committee was told in January that even in Torbay there was a danger of retreating back into a ‘silo mentality’ because of cuts in social care funding.
In some cases, organisations might end up being given a set pot of money to provide care for a defined group or for those following a certain care pathway – and freedom to spend it as they think fit. This sounds similar to the health care management and managed care organisations in the US. Kaiser Permanente, for example, stresses preventative care and co-ordination of care between providers.
For many though, the main question will be whether integrated care will put the NHS in a better position to meet the ‘Nicholson challenge’ and find the £20bn it is required to save by 2015. The evidence is not clear-cut that integrated care always reduces costs, says Goodwin.
In some cases, although people have been given support to remain at home, this has not reduced admission costs and bed use sufficiently to offset the additional cost. This might be because people are being picked up too late – when they already require hospital admissions and little can be done to keep them at home long-term.
Goodwin believes integrated care can reduce costs but to do so the right groups of patients need to be identified, access to care needs to be round the clock and all the pieces of the care jigsaw need to be in place. Introducing just one or two elements won’t produce the desired result.
He suggests that a relatively small number of people might need the intensive support and case management approach – but as they will be disproportionate users of health services there is scope for considerable savings. ‘Targeting the right people is very important to have a cost-effective result,’ he says. ‘I don’t think the system is quite intelligent enough to do that.’
Time is also needed: it took the Torbay Care Trust 12 years to make all the changes it needed. That makes integrated care something that needs to sit outside politics. A tall order in a climate of bitter controversy over NHS reforms and huge pressure to make cost savings.
The weakest link
Integrated care means different things to different people.
It is often used to describe a more joined-up approach to providing care for patients between different NHS organisations. But even this can be difficult. In Derby, for example, a new organisation had to be formed, involving both the hospital trust and GPs, to integrate care for people with diabetes.
Integrated care can also mean seamlessly providing both health and social care. In England, the 2006 NHS Act allows health budgets to be delegated or pooled with social care. This has led to some joint or lead commissioning, with one body commissioning a package of care across health and social care using the pooled funds.
Pooled budgets have been used by care trusts to deliver primary and community services, and adult social services.
However, the future of care trusts is now in doubt. Care minister Paul Burstow recently referred to them as an ‘experiment which did not really get out of the lab’ and did not lead to significant transformation.
Which raises the question – how will the Health and Social Care Bill’s ambition of more integrated care be achieved without the financial and structural means to do it?
