23.04.15
Do councils hold the key to integrating health and social care?
Source: PSE - April/ May 15
Councils could play a key role in integrating health and social care at the local level, providing they are empowered to do so, a new report has concluded.
The study – Unblocking: Securing a health and social care system that protects older people – by Localis, highlighted that the “institutional” and “historic” separation of the NHS and local government has fragmented healthcare provision locally and nationally, and created significant barriers to integrating services.
It says that as the NHS has historically been driven from Whitehall, it often sees itself as answerable to ministers, whereas local government is directly accountable to its electorate. The two environments inevitably have very different outlooks.
Fragmentation
Speaking to PSE, Alex Thomson, CEO of Localis, said: “Integration for health and social care has been an issue for nearly 20 years, but everyone involved will tell you that it has been long on rhetoric, short on delivery, to date.”
The latest report, which incorporates the results from interviews with more than 100 health and social care experts from around the country, highlighted the usual reasons for fragmentation: jealous guarding of individual service budgets, cultural differences, perverse financial incentives and a lack of joined-up leadership.
But they cited Health and Wellbeing Boards (HWBs) as a positive local structural lever for change – despite still being in their infancy. In fact, 75% of those surveyed thought that their HWB had made a noticeable or substantial improvement to health and social care in their local area, because they bring together leaders.
Thomson said: “The thing that jumped out for most people, and kept coming out again and again, was that getting people to sit at the same table to discuss the integration issue is a) absolutely necessary to achieve anything; and b) a big step forward.
“It all goes back to the ‘differences in culture’ point. The very fact that it has taken until very recently to get these people routinely in a room together to discuss the issues tells you how big the chasm has been between the two sectors.”
A move to prevention
NHS England boss Simon Stevens says the ageing population will require the country to “supercharge our work on prevention, on care integration, and on treatment innovation”.
Localis says prevention can only happen if health, housing and social care are closely integrated. HWBs are well-placed to lead this strategic shift – if they are given the teeth to do it. Thomson said more than a third of the survey’s respondents backed enhanced powers for HWBs to scrutinise contracts.
“But the most popular responses by some way were to allow HWBs to have strategic oversight of acute provision and to commission primary care in a partnership,” he said.
The report has also recommended that acute trusts should be made a statutory member of HWBs, to further break down fragmentation and enhance local healthcare system leadership.
Long-term budgeting
Localis also wants long-term pooled budgets, dictated by age groups and then commissioned jointly; though care would be needed to ensure this does not cut across existing integration efforts.
Two age groups in particular could benefit from this whole-system approach: 1) single commissioning budget focused on prevention around the 40-55 age group; 2) single commissioning budget focused on care provision for 85+ year olds.
“This pooled budget approach has got huge potential to promote truly integrated care and eliminate perverse incentives,” said Thomson. “However, steps must be taken to ensure that decisions are not shaped by short-term ‘political’ drivers and instead focus on the long term.
“One-year horizons make organisational planning much more difficult, therefore it would be beneficial to have longer term budgeting. This is because [short-term budgets] lead to all kinds of perverse things happening, such as using up underspends because if you don’t get them out by the end of the financial year, you don’t get it in the next year. It is the wrong way to do things, but currently this is the way the world works.”
The report suggests aligning these budgets to five-yearly Parliamentary cycles instead.
Indicative multi-year budgets for clinical commissioning groups and local authorities were pledged in the 2014 Autumn Statement – though this depends on the result of May’s general election.
Best practice
Localis has also suggested fast-tracking a practical and NHS-focused What Works Centre for Integration. This would be a best practise accreditor, staffed by national health, GP and council policy professionals, which would highlight innovative ideas that help integrate health and social care.
This “could be a big step forward,” said Thomson. “The Five Year Forward View, which NHS England came up with, is in tune with this, by trying different models and seeing what works locally. That is the essence of localism: you can’t sit in Whitehall – in SW1 where I am right now – and have an answer that works everywhere. Life isn’t like that.
“We think local government has an unparalleled capacity to help drive the necessary coordination between health and social care in order to deliver better care for older people, and others.”
Alex Thomson, chief executive at Localis, talks to PSE about the importance of Health and Wellbeing Boards in local integrated care.
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