Failed attempts to integrate healthcare services and social care services go back a long way. The National Health Service Act 1977 under Jim Callaghan’s government encouraged Health Authorities and local authorities to co-operate. The Health Act 1999 allowed NHS bodies to pool budgets. Successive governments have again and again tried to pull NHS bodies and local authorities closer together. However, it’s been 40 years of failure.
The House of Commons has been busy recently churning out extremely helpful and informative impartial briefing papers on various aspect of care. I’ve drawn heavily on one of these papers in this piece – ‘Health and Social Care Integration: Number 7902, 20 October 2017’.
One assumes the goals of this integration would be better patient/service user experiences, efficiency and cost cutting. The elephant in the room is that healthcare is funded and run by the Department of Health /NHS England, and social care is funded by the Department for Communities and Local Government and run locally by local authorities.
To continue the history lesson we had the Health and Social Care Act 2012 (‘..duty to encourage integrated working’) and the Care Act 2014 (‘..promote the integration of healthcare provision’). It’s unclear as to how much integration these statutory ‘encourage’ and ‘promote’ initiatives actually achieved.
The Better Care Fund
The Better Care Fund was announced in 2013. It was to be the primary funding mechanism for integrating health and social care. A key goal was keeping older and disabled people out of hospital. £200 million was immediately handed to local authorities. Spending the £3.8 billion Better Care Fund should have achieved healthcare and social care integration by 2018 – but it won’t have. In 2015 Better Care Fund was judged to be missing its bed reduction, elderly hospital discharge and independent living targets. Rather than saving on costs, costs rose by £200 million. An ‘improved’ version was introduced (iBCF). Another £1.5 billion was thrown at it. In 2017 Local Authorities were granted £2 billion for Better Care Fund 2017-2020.
There has been much criticism of the Better Care Fund. Apparently NHS England has effectively abandoned it. It seems the grant money wasn’t ‘new’ money but ‘old money’ re-purposed. Informed observers found unrealistic levels of bureaucracy and expectations. Only 30% of the Better Care Fund money has been spent on social care. There are certainly patches of successful integration throughout England but neither DoH nor the Department for Communities and Local Government has tried to measure integration ‘success’ or estimate Better Care Fund cost savings. The Better Care Fund was rendered largely redundant by NHS Sustainability and Transition Plans published in October 2016.
Integrated Care Pioneers
Launched in 2014 in 14 local areas, and in an additional 11 in 2015, some piecemeal success has been achieved. However the Policy Innovation Research Unit noted difficulties in accessing external support, and problems with data sharing, payment systems, and procurement provider viability.
Vanguards
50 were established in 2015 – often involving NHS bodies and Local Authorities. A National Audit Office report in 2017 highlighted some early integration successes but whether this success could be scaled up and sustained (post grant-aid), and deliver cost savings is debatable.
Health and Wellbeing Boards
The Health and Social Care Act 2012 required upper-tier local authorities to create these boards. The Act mandated Health and Wellbeing Boards with a duty to encourage integrated working. Boards are required to produce a Joint Strategic Needs Assessment – which looks at current and future local and social care needs. The King’s Fund in 2014 observed that many boards showed limited ambitions for integration.
Devolution
The devolution of health and social care to Greater Manchester was announced in February 2015. Care integration is a major aim. Care budgets (£6.2 billion) were pooled as from 1 April 2016. Although there are local integration successes no major integration ‘successes’ or cost savings have been publicised. In London, a somewhat less ambitious care ‘collaboration’ agreement was signed by 33 NHS CCGs, 33 local authorities, Public Health England and NHS England. There are three pilot integration projects in north east London, Hackney and Lewisham. They began in April 2017 and apparently don’t expect success until April 2019. Care integration across London is not a collaboration goal. In Cornwall (2015), Liverpool (2016) and Cambridgeshire and Peterborough (2016) moves towards devolved integrated care are underway.
Sustainability and Transformation Plans
Sustainability and Transformation Plans describe how a region will meet the needs of the NHSE Five Year Forward View objectives published in 2014. Implementing Sustainability and Transformation Plans must collectively cut annual healthcare costs by £22 billion by 2021.The integration of healthcare and social care is one of the stated goals for all 44 STPs. However details on the social care side of the integration equation are thin on the ground in many STPs. Given that 43 of the 44 STPs are run by NHS executives this healthcare bias is perhaps understandable. The Local Government Association and the Public Accounts Committee have both expressed concerns about STP care integration. The Local Government Association’s main concern is the lack of involvement by local authorities in the creation of STPs, and how STPs will interact with local authority Health and Wellbeing Boards’ integration plans. The Public Accounts Committee sees the risk that integration will become sidelined in the pursuit of NHS financial sustainability.
Mental Health
Sadly it’s no surprise that the House of Commons briefing paper makes no mention of integrating mental health care services with mental health social care services. Ignoring mental health needs has been a national pastime for decades. The NHS and local authority care resourcing crisis is probably most acute in mental health.
Accountable Care Organisations
Although completely ignored by the House of Commons briefing, Accountable Care Organisations are clearly planned to be the implementation ‘engines’ for cost cutting and care services’ integration. Accountable Care Organisations will have 10/15 year, fixed price contracts to deliver specific services to specific populations. They will use capitated budgets i.e. a standard, fixed annual budget for each service user. Will these organisations finally deliver care integration? The answer to that is that no-one knows. Many of the contracts will be £multi-billion ones – and nowhere in the world have Accountable Care Organisations been even attempted on this scale.
This is a jargon littered arena. We have Accountable Care Systems, Accountable Care Partnerships, Multispeciality Community Providers, Primary Acute Care Systems and Accountable Care Models. The DoH is hoping to get Parliament to agree to new regulations in February 2018 which will allow Accountable Care Organisations, amongst other things, to commission integrated care services. Pioneer Accountable Care Organisations start date is 1 April 2018 – but the NHS rarely hits its target start dates.
There is precious little evidence (or public confidence) that the STP/ACO approach (by those who know about it and grasp the significance of it) will achieve successful healthcare and social care integration or in fact meet the cost savings targets by 2021 or at all.
Disintegration
Whether healthcare services and social care services are integrated or kept as separate services, is a moot point if the human resources and facilities needed to deliver each of the services are inadequate. Consider:
- The number of care/nursing home beds is decreasing – because of rising costs and falling revenues
- The numbers of Acute hospital beds and hospital A&E units are decreasing – because of Government/DoH/NHS England policy
- There are significant shortages of trainee and trained doctors, nurses, mental health staff, social and healthcare support staff – because of cost cutting, the salary cap, bursary removal, student debt, medical schools’ capacities, overwork and Brexit fears
- Much of the NHS estate is old, not fit for purpose and needs refurbishing/replacing – however the DoH/NHS England approach is to empty the buildings and sell off the land
- NHS staff and local authority staff don’t understand each other, don’t trust each other and don’t want to share data – according to NHS England Director Professor Keith Willett.
Maybe the sensible approach would be to accept that 40 years of trying and failing to integrate is quite long enough as a learning exercise. What we need is both the healthcare service and the social care service to be adequately funded, resourced, equiped and ‘housed’ with clear handover interfaces between each other.
Yet Another Revolution?
It would take a major revolution to scrap the NHS and Local Authority social care services and replace them with a new National Care Service which would provide integrated healthcare services and social care services both free at the point of use. I don’t think we have got to that point where yet another revolution looks like the best option.
However, it maybe that we have already embarked on creating this new care body. As from 1 April 2018, in theory, England will start to be covered by Accountable Care Organisations which presumably will take over from CCGs and local authorities in commissioning healthcare, social care (Public Health?) and the integration of the two. This will make NHS CCGs and local authority social care commissioning organisations redundant. Now imagine a national organisation being created which would manage all these Accountable Care Organisations. An ‘Accountable Care England’ could be set up and would in effect be this new National Care Service, which would make NHS England and probably the NHS itself redundant. All this is speculation on my part as the ‘cunning plan’ no doubt hatched at the World Economic Forum in Davos in 2012 has not yet crept into the public domain.