There is no doubt that there is general and wide ranging agreement that health and social care services need to be much better co-ordinated so that person centred care can be facilitated more effectively throughout the care pathway. There has been consistent recognition of this for many years and successive governments have wrestled with the concept without notable success. More recently the 2013 Barker report recommended that ‘England moves to a single, ring-fenced budget for health and social care with a single commissioner’. The so called Better Care Fund was established as a first step towards this vision. However, stakeholders, in particular the NHS and Local Government, have since struggled to convert this into a practical modus operandi considering the major organisational changes that would be required. Some commentators conveniently describe this as cultural resistance.
Despite this, the case for better integration between different types services between health and social care is now universally accepted so the search is now on to find a workable plan to deliver it, based on the central principle of ‘person centred co-ordinated care’. Evidence suggests that integrated services can produce notable benefits, particularly for older people, with their increasing numbers as a proportion of the overall population and complex long term conditions leading to a reduced dependency on acute and emergency services. It is important to recognise that integration should not be seen as an end in itself but rather a means to better outcomes for individuals.
Cultural resistance seems to be based on the stark differences between how health and social care is commissioned. Health services are largely free at the point of delivery protected by a ring fenced budget, whereas social care budgets are not ring fenced and exposed to Government austerity measures and Local Authority judgements on setting fees. The local element in this is leading the debate towards finding local solutions to integration such as the Manchester example, where budgets have been wholly integrated. Whilst there remains a need to have a single commissioner, as proposed by the Health Committee, it could be achieved in a more roundabout way with the natural evolution of the duties of local health and wellbeing boards. The Integrated Care and Support Pioneers programme announced by Government in 2013 has led to 25 or so around the country, each with a proposed integration programme that best suits their local needs and by this year seem to be showing some encouraging results for the integration agenda. On the other hand, the King’s fund analysis of the strength of role of health and wellbeing boards shows that ‘local authorities are more positive in their assessment of the health and wellbeing board’s importance than are CCGs: 67 per cent of CCGs rated their health and wellbeing board as three or lower on a scale of importance, while 69 per cent of local authorities awarded their health and wellbeing board a score of four or higher. Given that local authorities typically host health and wellbeing boards, this may reflect a sense among CCGs that their influence over their health and wellbeing board is limited’.
It is widely seen that the strongest way forward is to develop the health and wellbeing boards as the single commissioning force behind integration – both the Health Select Committee and ADASS and Local Authorities endorse this, along with cross party backing although, interestingly, Clinical Commissioning Groups did not – perhaps an example of the cultural resistance mentioned earlier. Clearly, for this to carry any weight the health and wellbeing boards will need broader representation, particularly from providers, stronger decision making powers and better funding, what the Kings Fund describe as health and wellbeing board plus!
If this is to be the way forward then the ‘centre’ would need to set the guiding principles including the expected outcomes from a single commissioning body and for that body to demonstrate achievement of those outcomes including the focus towards total budget integration which, itself would include social care, community health, public health, primary, mental health and defined acute services. Thus, a clear definable person centred care pathway across all local services against sensible and achievable timelines and without further massive and dysfunctional organisational change, could be achieved.