Integrated Care

Ailsa Cameron and Rachel Lart – Is integration the Burning platform for change – a literature review.

• The imperative is because Integrated care gives a better experience of care
• If “state” and public services have a role in wellbeing it should perform that role well.
• No evidence it delivers better outcomes
• No evidence it delivers cost savings in fact better care may translate to higher demand and greater cost
• Been tried in theory many times little success – a tiny number of local efforts have gone well – usually by bending governance rules
• Not just about health/social care integration – has to be much wider
• There is major dis integration within health and within local authorities
• The Health & Social Care Act makes the goal of integration harder to achieve
• Organisation integration is not in itself a panacea for Integrated Care at patient level
• Delivering Integrated care will require changes to rules around governance across organisations and huge changes to Information Technology and data
• Use of legal contracts with providers (as in a lot of Social Care) militates against Integrated care if the contracts bring inflexibility – nature of contract relevant not nature of provider.

• Better integration within existing organisations would be a good starting point
• It could reduce barriers to Integrated care but is not a solution in itself
• Some integration of the commissioning of services must bring benefits and savings
• Integrated Care Organisations may or may not be a good thing – networks or partnerships or even just intelligent commissioning may be enough
• The history of exhortation followed by failure shows any attempt will face massive cultural resistance
• Big issues around health/social care integration due to professional silo based resistance, cultural barriers, funding and governance
• No progress will ever be possible whilst NHS remains an empire in its own right and effectively walled off from other public services.

Prof Gerald Wistow’s presentation

Christain Brand Et al study of Community Mental Health teams

Prof Bob Hudson:

Alex Fox, CEO, Shared Lives Plus:

I want to suggest that integrating health, social care and other services will not be enough to achieve public health outcomes and improve the self-management of long-term conditions. We also need to integrate the paid and unpaid, formal and informal caring systems, creating new, more integrated relationships between citizens and professionals.

When faced with huge challenges like providing healthcare to an ageing population, it’s reasonable to assume that only huge solutions will do. The problem with that way of thinking is that, whilst some healthcare activities need to take place on a large scale, achieving health itself happens, or fails to happen, at the micro level, in the relationships between individuals, families and communities. Big buildings are sometimes the best place to treat illness, but achieving health generally happens in our own homes, workplaces and communities.

The only way to make sense of that conundrum (big challenges with as many different solutions as there are people) is to push as much of the power to design, control and deliver solutions into the hands of individuals, families and communities as possible.

Social care has gone a little way down this road, at least in its aspirations, if not always in its implementation. Healthcare has, in my view, barely started on this journey and the lack of integration between the health and social care visions is striking in this respect:

The vision for healthcare is that patients will become informed consumers of the choices designed and commissioned for them by GPs and other professionals.

The emerging vision for social care is that citizens will not only be able to choose from the offers of providers and professionals, but also to take charge of commissioning and to pool their resources to design and own new services and enterprises when there is not an existing solution available to them.

Mix in healthcare circles and you will hear “clinical leadership” rather than “citizen leadership” and “patients” rather than “people”.

The comparisons I’m making are not entirely fair on the healthcare sector. If I ever need emergency brain surgery, I probably won’t even be that interested in having a choice of services, let alone wishing to commission a service myself from a cottage industry brain surgeon. There are some treatments and interventions which are best done on a large scale by experts who do the same thing day in, day out. But our aspirations for the NHS are not just for it to be a great illness treatment service, and nor can we afford all the great illness treatment we will need according to current demographic projections. It’s when we start to look at the prevention and management of long term conditions that you can most fruitfully apply the lessons from social care’s attempts to personally tailor solutions and then more recently, to co-produce or share responsibility for those solutions with citizens. Doing this badly, leads to people feeling dumped by services which seem to take less responsibility but to have given up none of their power. Doing this well unlocks abundant resources which the NHS currently cannot reach.

At the heart of these ideas is the concept of taking an ‘assets’ approach to the people with whom we come into contact. I recently led on prevention for the social care White Paper engagement process and we came to the conclusion that successful prevention required two things – integration (otherwise it was just cost shunting) and an assets approach. This means refusing to see anyone as merely a collection of needs to be met, and instead working with them to look for their skills and potential to take charge of their own life and to contribute something to services and those around them.

So the young woman with Down’s Syndrome who couldn’t find work in dance, is now supported to be the director of her own dance activities business, leading dance activities with a dozen disabled and non-disabled dancers. A man with mental health problems leads guitar sessions with other people with mental health problems, in a club currently working on its second CD. He has started to deliver guitar lessons and sessions on an acute ward as part of moving back into the workplace.

Apply assets-thinking to healthcare and you have the recognition that people can be expert patients. You have the RCGP’s drive to get GPs to recognise that unpaid family carers can be expert partners in care. You have people with mental health problems forming peer networks of mood buddies.

Shared Lives is well established as a family-based approach to support in social care. Approved Shared Lives carers are matched with adults who need support; they then share family and community life. A person with dementia may visit an approved Shared Lives carer in the carer’s own home instead of visiting an impersonal day centre. Thousands of people with learning disabilities live with a Shared Lives carer and their family instead of living by themselves or in a care home. People labelled “challenging” have moved from some of the remaining NHS-commissioned special hospitals and so-called assessment centres (costing up to £3-5000 per week) into successful and happy Shared Lives arrangements (costing £3-500 per week). The first Shared Lives service for people with mental health problems who are in the acute phase has just been set up, combining the support of Shared Lives carers and their families with round the clock professional back up to keep people out of hospital. Shared Lives is also being developed as intermediate care for older people who have multiple hospital visits and might prefer to stay in a familiar family home each time rather than a succession of step down care homes.

The challenge back to these kinds of highly personal approaches is that, by their nature, they can’t become a big part of the overall solution. If you try to scale them up, you destroy what made them valuable, which was that they were based on close, personal relationships and intimate community knowledge. That’s true, so instead of scaling up, we need to scale out. This means creating the conditions in which micro approaches are the norm, not the exception, so that you no longer have to be an exceptional, inspirational social entrepreneur to be able to create an enterprise which can survive and thrive, just someone who understands what works in your field and knows where to access the support to turn that good idea into a viable enterprise.

To some extent, that’s already happened with Shared Lives, where a combination of national infrastructure, relatively light touch regulation and the endless variety of family life has combined to create a sector now supporting around 15,000 people. But we’ve got so much further to go. Like many daunting journeys, we will get there by having the courage to take not a few huge leaps, but a million small steps.