The separation between British health and social care has survived far longer than the iron curtain that divided Europe for 44 years. Winnie Agbonlahor looks at the government’s latest efforts to marry the two core services.
The idea of integrating health and social care has been around for some time. In 1997, former health secretary Frank Dobson declared that he wanted to break down the “Berlin Wall” between health and social services. In fact, says Stephen Dorrell MP, chairman of the Commons’ Health Committee, “we’ve been talking about this for the best part of half a century”. But, he adds that “we haven’t been at all good at doing it”.
There have certainly been many initiatives and pilots over the years. A review of the NHS by Lord Darzi, published in 2008, articulated the need for previously fragmented services to be better coordinated and integrated. This was reinforced in the Equity and Excellence: Liberating the NHS white paper, published in 2010. In the same year, the Department of Health (DH) launched its Integrated Care Pilots programme, which saw 16 areas explore different ways of providing integrated care over two years.
Nevertheless, things have not progressed considerably. Norman Lamb, minister for care and support, says that instead of merging the two strands of care, we have “institutionally separated” them, resulting in a split he describes as “crazy” and “not in the interest of the patient”. This, he says, urgently needs to change, not least because the older we get the more complex our medical needs become, often requiring a combination of health and social care. By the year 2030 the number of people over the age of 85 will have doubled, he says. This “extraordinary” trend, he adds, puts “immense pressure on our system already under quite a lot of strain” and “forces us to think fresh about how we do things”.
Dorrell agrees – he believes integrated care is “long overdue”, adding that it will also bring financial benefits. “Every time information is collected twice or double-entered, not only is there a serious risk of the care being poor, but also of the cost being high,” he explains to CSW.
Coalition reforms
The coalition’s health reforms are intended to give this agenda a real push. A £3.8bn pooled budget for health and social care will be created in 2015-16 – the ‘Integration Transformation Fund’ (ITF), run by NHS England and the Local Government Association. The DH believes this money will “break new ground in establishing structures that will drive further and faster integration between health and social care”. What’s more, changes to the Health and Social Care Bill have already handed duties to promote better integrated care to the new NHS Commissioning Board, economic regulator Monitor, clinical commissioning groups and health and wellbeing boards.
Earlier this year, the DH and a range of national partners published a commitment to help local areas integrate services in a bid to “make integrated care and support the norm” by 2018. Another pilot is due to start, this time under the banner ‘Integrated Care Pioneers’. Out of 110 areas that applied to take part, a shortlist of 28 has been picked and will be further whittled down to 10-15 later this year, piloting new approaches over the course of up to five years.
So what needs to happen now to break through the organisational boundaries once and for all and to finally integrate social and health care? “You have to get the leadership of the key organisations [involved in the care delivery] agreeing that it is worth putting energy behind sorting this out,” says Dr Rebecca Rosen, senior fellow at the Nuffield Trust. The key, more often than not, she adds, lies in “the people, innovators pushing it, rather than organisational barriers”. Her view is backed by Jules Acton, director of engagement and membership at National Voices, a coalition of health and social care charities in England that helped the government devise a narrative for defining integrated care. “Every organisation sits on the receiving end of a lot of guidelines, so we need people locally to look across organisational boundaries and see how we can work around them; we need great leadership, not just from the top [of the NHS], but in every organisation,” she says.
How can senior civil servants help to further this cause? “They can be more permissive, encourage people to take risks, support them, don’t sack them if they get something wrong,” Rosen suggests. A fear to “get it wrong and lose their job” has made many public servants fundamentally risk-averse and reluctant to experiment, she adds. Her views are echoed by Dorrell, who tells CSW that giving greater freedom to local areas to test different approaches is key to success. “I’m not in favour of central government standing back and saying ‘see what you can do,’ but the worst way of doing this would be to have some new holy scriptures by Richmond House on how this should be done,” he insists. “We have seen local examples of success, but they haven’t been sustained and rolled out at scale, so we shouldn’t assume that we know how to do it, because we have limited experience of doing it successfully.”
Integrated care – a local case study
One example of a local area creating its own system of integrating care can be found in Nottinghamshire: a one-year pilot scheme called PRISM (profiling risk, integrated care and self-management) – designed to provide joined-up care for patients with long-term conditions and thus reduce emergency hospital admissions for these patients – was completed last year. The programme was designed and implemented by Jan Balmer, associate director of integration and unplanned care on the Newark and Sherwood clinical commissioning group (CCG), and she is now in charge of fully embedding it as well as rolling it out to Mansfield and Ashfield CCG, also in Nottinghamshire. This forms the Mid-Notts Transformation Programme.
As part of the programme, patients are admitted to so-called ‘virtual wards’, putting them under the formal care of multi-disciplinary health and social care teams, which meet weekly and are led by a ward manager. Upon admission, patients are assessed on their risk of hospital admission, using a computer tool, which combines and matches different sets of data, such as age, gender, recent hospital admissions, A&E attendances, or calls to out-of-hours GP services.
One challenge arising during the course of the pilot, says Balmer, was that of convincing medical professionals of the reliability of this risk-profiling computer tool. “Evidence shows that this computer algorithm is far more accurate than clinical judgement,” she says. “But for a lot of doctors that is quite difficult to get their head around. A patient might come up on the risk tool as showing 99 per cent risk of hospital admission or having a crisis in the next six months, but his GP might think he is fine because he has not seen him for two years. But the GP might not know that his patient has been to A&E every month for the last six months,” she adds.
Another tricky task, according to Balmer, has been helping professionals on the ground to understand the benefits of the new approach. “We are very traditional in the NHS, so it took a while for people to understand the impact the new programme was going to have on them and what they needed to do.” One of the most difficult aspects of the change, she says, has been explaining that the work would change rather than increase. “If you go to people and say ‘we want you to do XYZ’, they always assume they don’t have time to do XYZ because they’re too busy doing ABC. It took a while for them to understand that actually we wanted them to stop doing ABC.”
Communication, she says, is essential, because it is “very difficult to drag people into something; they have to go into it willingly”. She adds: “You have to take people with you and not implement a complex programme without making sure that the people you rely on to deliver on the ground are absolutely on board and with you.”
New challenges
Aside from achieving consensus among the parties involved, there have been other more fundamental problems. Amanda Sullivan, chief operating officer for Newark and Sherwood CCG and senior officer responsible for the Mid-Notts transformation programme – who proposed the extension of the pilot – explains: “We have managed to do a lot of the integration work locally ourselves through creative ways of working, but the biggest challenge has been around information sharing.”
She tells CSW that before CCGs became fully operational earlier this year, primary care trusts (PCTs) were responsible for commissioning primary, community and secondary health services from providers, and also provided community health services directly. Under the old system, the PCTs were exempt from the common law duty of confidentiality, enabling them to access, process and share confidential patient information between the services they oversee and run. However, this exemption was not passed on to the CCGs, causing “major problems” for integration, especially patient risk profiling, she says.
The government has issued national guidelines on how to get around these issues within the law. But Sullivan says these are “quite ambiguous at the moment”, and calls on the government to put in place a clear mechanism by which CCGs can access and process personal patient data – something necessary to risk-profile patients. “People in the system are sometimes frightened, don’t want to take the risk or get into any trouble. But it gives us certain constraints in taking forward integration,” she says. Her concerns are shared by Martin Roland, professor of health services research at the University of Cambridge, who worked on the evaluation of the 2010 Integrated Care Pilots. He highlights information governance as a major challenge, adding that central government should be “more permissive about data sharing agreements that promote integration”.
Another major issue lies in funding arrangements that create perverse incentives. The split between primary and secondary care, Roland says, “potentially gets in the way of integration”. He adds that the current system of paying hospitals per admission – the more patients they admit the bigger their budget – presents a major problem, because they have no incentive to cut admissions. According to Rosen, that’s why the financial and payment mechanisms are aligned and explains the incentives for collaboration, echoing the views of Sullivan – who believes providers “will need to be incentivised to work together”. Balmer, on the other hand, disagrees: “Personally I don’t think paying someone money to do something is going help in the long term, because the moment you stop paying them they will stop doing it. People have to believe that it’s the right thing to do.”
How can we get it right?
One of the key questions to answer, Rosen says, is: “How you can get contracting and commissioning currencies that support integration?” One approach currently being applied to a number of pathways in the NHS, whereby one prime contractor – for example the CCG – would deliver integrated care, but contract manage all other providers involved. Another model, already applied in some areas of New Zealand, is the alliance contract model, which works on the basis of equal, but separate parties, who work together collaboratively to deliver elements of a care pathway or service. Both, Sullivan says, are approaches being looked into in Nottinghamshire.
One way to implement integration within the existing legislation, according to Roland, would be greater collaboration between hospital consultants and primary care providers in work to avert hospital admissions. “If CCGs pay for them [consultants] to go out into the communities to help prevent people going into hospital, it could be done within present regulations,” he says. There would be a contract between the CCG and the hospital trust for that consultant’s time, meaning the hospital gets paid, the CCGs save money on hospital bills, and “trusts can use their consultants to help maintain people independently in their communities”.
Furthermore, Roland is urging the government to allow plenty of time for the imminent Integrated Care Pioneers to determine what works. In the pilots he evaluated, he says, one programme in Wakefield “did not succeed in getting the data integration they had planned by the end of the two years”. He also questions the effectiveness of focusing on patients at high risk of hospital admission. “It’s fine to focus on the high risk group – but not exclusively, because the majority of people admitted to hospital come from medium to low risk groups,” he says. And the assumption that moving care into the community will lead to a shrinking need for hospital capacity, he says, is “untested”, because “we really have not managed to reduce admissions: they have been going up year on year”.
Overall, Rosen says, there are some “key ingredients” to enable better integrated services: tying together IT, better data exchange, financial incentives, leadership, shared goals and objectives, and clinical support mechanisms. “If you can get all of them right, then you’re more likely to achieve more integrated services; if you don’t, it becomes harder.” Some people, she adds, have already got some of these elements right. “But they rarely elide in the same health economy. There are people around who are experimenting with integrated contracting, with integrated data systems, but they don’t often come together in the same place.”
Sullivan agrees: promoting a national drive and letting local areas create their own ways of working is helpful because it gives them the necessary flexibility to meet their population’s needs. However, there is also a danger of ending up with “pockets of innovation and other areas not progressing”. To avoid this, Lucy Dadge, director of transformation for Mansfield and Ashfield CCG and Newark and Sherwood CCG, who works with Sullivan on the integration programme, says information exchange is crucial: she adds that if government ensures there is a “pool of knowledge” that everyone can tap in to and contribute to, the Pioneer Pilots will present a “fantastic opportunity”.
Government’s response
Lamb recognises the problems around data sharing, which have also been highlighted in a report by independent think-tank Localis: In Sickness and in Health, released last week. Speaking at the launch of the report, Lamb said that the current situation – with different care providers struggling to share data about a patient they’re trying to support – is a “nonsense and has to be tackled”. To this end, he said, government is establishing a central unit within NHS Improving Quality, which will include a range of experts offering advice and guidance to the pioneer pilots on issues such as “legal aspects on the rules of procurement, payment systems and the fundamental need for us to move away from payment [per admission]”. Lamb said he is “very keen” to resolve this, but added: “It’s a work in progress; but often it’s not about actual rules, but perceived problems and people being fearful.” The unit will provide one account manager per pioneer pilot and they’ll act as a go-between between national and local partners. The DH is still determining how long these will be in place.
Lamb also said health and wellbeing boards will have to work with CCGs and local authorities to come up with a plan for how to spend their share of the new transformation fund due to be distributed in 2015. “This is potentially a revolution of how care is delivered in this country,” he added. And while this “revolution” is something health and social care professionals – as well, of course, as patients – have been awaiting for many decades, there are still some significant obstacles which will have to be overcome.
Sullivan notes: “We like trialling and testing things, which is right and proper. But sometimes we’re not bold enough: where things do appear to be working, we often fail to implement them on a larger scale.” Government now needs to ensure it learns lessons from the pioneer pilots, acts on them, and then puts in place the right legislative and political framework to enable a country-wide roll-out of this new approach. Then, perhaps, we will finally be able to not only climb over and knock holes into the great divide, but break through and tear down the ‘Berlin Wall’ separating health and social care.