The care commitment

12 Jul 13

Integration of health and social care was always going to be tough, but never before has there been such an unambiguous commitment to it, from the top of Whitehall down to town and county hall, GP practice, hospital and beyond

It wasn’t a survey. It was a snapshot of opinion among adult social care directors and local health commissioners. But it has given NHS and social care leaders on the ground, as well as civil servants and politicians, plenty of food for thought.

Integration has been a cumbersome set of ideas to wrap around into a single policy. For many in the health service, it was too easily considered to be about integrating internal silos: community, primary or acute.

And although it has never had a strong presence in local authority parlance, the current drift towards (re)integrating adult and children's social care shows that it's alive in the social care sector, and beginning to kick a little bit harder.

But where it matters to ministers and civil servants, and where the main impetus of the current political impetus is located, lies in the efficiencies, better care and – yes, savings – that can be achieved where adult social care and services locally are aligned in such a way as to relieve pressure on the acute sector by boosting adult social care in the community.

As health select committee chair and former Secretary of State Stephen Dorrell put it at a recent Strategy Society event, One Budget, One Care, although the health service has undergone many reorganisations since its inception, it has never undergone the sort of profound change needed now.

Demography requires a shift away from treating one-off medical treatments to a situation where the majority of `customers' come presenting chronic care and medical symptoms that will be lifelong. Hence the realignment that only a substantial measure of integration can bring about successfully.

The Care Bill and the spending review recently laid bare the financial sticks and carrots the government will use to help bring this about. The Local Government Association even more recently launched its major report into `re-wiring adult social care', extolling integration. Now we in the Association of Directors of Adult Social Services and the NHS Confederation have shown – if only in a snapshot – what's happening on the street.

The bare bones, even from a relatively small sample, give cause for a lot of optimism. Respondents reported that where integrated care was achieved, it had reduced pressures on services in their localities in the following ways:

* 57% saw a reduction in delayed discharges from hospitals

* 42% saw a reduction in unplanned emergency admissions

* 41% saw a reduction in the number of interventions across health and social care

* 41% saw an increase in the proportion of older people still at home 91 days after being discharged from hospital into rehabilitation

* 55% saw more effective sign-posting to low level interventions (including information advice and guidance)

* 48% reported quantifiable financial savings made, with 29% seeing cashable savings

* 46% reported that where they had developed integrated care, it had improved quality of life for people with long term conditions;

* 42% saw improved quality of life evidenced through patient/ user surveys

* 45% saw improved patient/service-user satisfaction

* 39% saw improved carer satisfaction

These are big gains and should give everyone the enthusiasm to go on looking at new ways of using integration to achieve these sorts of ends. With the Pioneer bids now into the Department of Health from those authorities wanting to take realignment even further, they are an especially important source of optimism.

As indeed are the main obstacles to integration a source of concern. In a political culture where the way to unlock the benefits of integration is seen as removing the obstacles (rather than inserting prescriptions) clearly the most urgent is communications: Dorrell’s speech stressed the enormous increase in telecommunications over the past 30 years as one driver for change.

But that can only be effective if the enhanced communication systems within and between agencies speak to each other. At present they strain to be understood.

Since 2010, organisational complexity and changing leadership have often been seen as barriers to reform. Now, half our respondents saw different cultures as a hindrance – and this has become comparatively more important since 2010. And, yes, payment mechanisms and financial pressures are another key barrier.

But it was data and IT systems that were most often cited as a hindrance – by almost two thirds of respondents.

As Terry Dafter, chair of the Adass information management group, put it in a recent blog: ‘Unlike in health there has been no earmarked investment for social care systems nationally since the Information for Social Care Grant. It is also a view of the social care sector that initiatives within the Department of Health have been very health centric: consideration of social care implications tends to follow at the end of the work rather than at the beginning.’

And he added: ‘There is a culture of suspicion between many agencies about the benefits of information sharing which becomes even more complicated when the voluntary sector is considered."

There were many other key features emerging from this snapshot, and the full results can be found here. But, overall, the importance of local leadership and commitment proved to be the greatest spurs to integration: personal budgets and health and wellbeing boards the least – but in fairness, these two latter developments are only in their infancies and will undoubtedly prove more vital as we move on.

Integration was never going to be easy, but never before has there been such an undivided and unambiguous commitment to it, from the very top of Whitehall down to town and county hall, GP practice, hospital and beyond. Today's snapshot is an early promise: we shall expect that promise to be fulfilled when we ask similar questions over the coming years.

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