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A vision for health and social care reform

The Government’s announcement that it is postponing the implementation of the 2016 Care Act changes, reiterated its support of integrating health and social care. It is now imperative that the two sectors come together and reform their ways of working to protect the whole system. With that in mind, two leading names in social care and health have published their proposals for reform. Is this the solution?

Anyone operating in social care is aware of the importance of integrating health and social care. We have a perfect storm of an ageing population, increased numbers of people living with long-term conditions, squeezed local authority budgets, discrepancies between the fees paid by private clients and councils, high staff turnover, increased operating costs and that’s just social care.

The NHS is at breaking point, accident and emergency departments can’t function through the winter, there are insufficient beds to meet demand, older people are admitted to hospital and then struggling to get back out again leading to bed-blocking, amongst other things. It’s obvious something needs to change.

When it comes to funding, the NHS budget is protected, with the Government committing in the recent Budget to increase spending by £10bn per year in real terms by 2020/21. Although some of this money has to go towards service transformation including integrating with social care, the social care budget via local authorities is continually being squeezed. However, they work hand in hand, if health and social care came together costs could be saved, lives could be improved and pressures on all services could be reduced.

Vicious circle

A new report by Ian and Stephen Smith sets out plans to reform the systems and address the ‘vicious circle of a broken down health and social care system’.

Ian R Smith is a leading name in social care. He is the Chair of Four Seasons Health Care and has held a number of high profile positions in business including Chief Executive of General Healthcare Group which owned and operated private hospitals.

Professor Stephen K Smith is a Professor of Medicine who set up the first academic health and science centre at the Imperial College Healthcare NHS Trust. Together they have published, in a personal capacity, their proposals for the reform of the health and social care systems. Originally published in the Health Service Journal, Away from the past and to a sustainable future. How the UK’s health and social care systems can be reformed to better align with the needs of today’s society, sets out their vision. This includes a new type of integrated care organisation keeping people out of hospitals. Hospitals themselves will become academic health science centres consolidating clinical practice and research to deliver personalised medicine to improve health outcomes. They argue that the existing structure of specialist facilities currently in local hospitals isn’t the best way to meet patient needs.

Integrated care organisations

The integrated care organisations that they propose will remove the boundaries between health and social care, acute and chronic medicine, generalist and specialist skills, primary and secondary settings, episodic and preventative interventions and physical and mental health.

The model would enable health and social care providers to work together to deliver care focusing on the individual that manages their needs, whether physical, social or mental. It would bring together GPs with social workers, mental health experts, pharmacists and diagnostic technology in large health centres.

The model would support personal, lifetime care pathways rather than individual episodes of care (such as from home, to intermediate care facilities, to hospital and back home), with each patient having a ‘case manager’ who will navigate them through the system. This would be made possible by a rapid introduction of electronic patient records in a connected digital network.

Clinicians would be separated into generalists who would consider the ‘whole person’ in their social setting and specialists based within hospitals, advancing medical science and practice. While the integrated care organisation would need to draw on a balance of specialists and generalists, they say that there is a strong case to consolidate the specialist expertise, for example, in cardiology or cancer into centres of excellence. This will mean fewer but larger clinical units.

Moving forward with reform

Ian and Stephen agree that there needs to be a strategy for reform to integration – something that is echoed throughout Government, think tanks and wider sector leaders. However, they are realistic to the barriers, including constant reorganisations affecting the system, complex management structures, an under-supported workforce, fragmented regulation, funding constraints and, of course, politics.

Ian Smith explained, ‘We do not under-estimate the enormous political challenge involved. This is in no small part because for more than half a century the NHS has been an election campaigning issue, with the major parties vying to persuade voters they can be trusted to ensure its future. This has created the public expectation that the ultimate goal should be to preserve the status quo.

But perpetuating that myth does our society a great disservice and in the long-term it is unsustainable. There is a compelling case for change to put the UK again at the leading edge of health and social care outcomes, just as the establishment of the NHS and social care systems did in 1948.

The integrated care model that we propose is realistic and achievable, but we recognise that others may have thoughts on how health and social care could be developed.’

Over to the experts…

There are many thoughts and strategies for reforming health and social care. If it is universally agreed that integration is the best way to ensure sustainable services, fit for the future, are the integrated care organisations proposed here the solution? Also, how do we get the reformed system that is so desperately needed?

Will take years of sustained effort

Ian and Stephen are absolutely right to identify the need to develop integrated models of care in response to demography and changing patterns of needs. This has been a goal of successive governments for over 40 years but achievements have been limited. This should warn us that achieving integrated care at pace and scale is difficult and complex. But our work on hospitals that have begun to develop integrated models and integrated care organisations in other countries offers some helpful pointers. In most of these places it has taken years of sustained effort.

Building up trust and effective relationships has been more important than organisational change alone. There are no short cuts. Whole system governance arrangements that engage the resources and expertise of other agencies are vital – especially winning the support and commitment of primary care.

Establishing integrated care organisations would almost certainly require parallel changes in commissioning, with a shift towards population-based capitated budgets that incentivise care outside of hospitals.

With England’s current complex commissioning landscape, doing this without structural reorganisation would be tricky. A different regulatory model would also be needed, geared to monitoring the performance of the whole system, not separate organisations, in achieving joined-up care. If this was hard to do when the economic sun was shining, how much harder it is in the toughest financial climate in living memory? But the alternative, to persist with fragmented, unco-ordinated services, will not be sustainable. Examples from UK and abroad show what can be achieved with the right vision, leadership and realism about how long it will take.

Richard Humphries, Assistant Director, Policy, The King’s Fund 

Part of the answer is more integrated working

It’s not only in the long-term that the system is unsustainable. £18bn in local authority (LA) budget cuts have left 150,000 older people without homecare, and cuts in fees have led to providers cutting back services, or leaving LA contracts. The growing split between self-funded and publicly-funded care is just as apparent in residential care, with the new minimum wage likely to put more pressure on staffing numbers.

Despite relative protection, the NHS budget is also creaking. NHS trusts were in the red by £822m in 2014/15. A recent King’s Fund survey found 89% of Finance Directors planning for even bigger deficits this year, possibly up to £2bn. This is before the £22bn in savings promised in the NHS Five Year Forward View (FYFV).

Wherever they operate, people are under pressure to make more income or savings, without considering the impact on the wider system. Trusts, for example, have every incentive to admit patients: the more they admit, especially ‘cheap patients’ not requiring complex care, the more money they make. This doesn’t help to advance the community care advocated in the FYFV.

Part of the answer is more integrated working; sharing of roles and resources. The New Models of Care, especially the primary and acute systems outlined in the FYFV, will come close to the Integrated Care Organisations. Getting organisations to focus on this locally can work, so the devolution models will be interesting to watch. In the USA Accountable Care Organisations are enabling significant cost savings.

This takes time. What happens if the need for short-term financial savings trumps longer-term goals? The Vanguard sites are showing what can be done through new approaches; it would be a tragedy if that were squandered.

Debbie Sorkin, National Director of Systems Leadership, The Leadership Centre 

This deserves to be explored

The sector was half expecting the announcement to delay the implementation Care Act’s financial reforms. The National Audit Office report into Phase One’s implementation, although more positive than reported, rightly pointed toward the significant and growing gap between the Act’s aspirations and the funding available. Add this to the additional costs of raising the minimum wage and the lack of progress on developing private financial products for long-term care; and the reforms have looked progressively less likely.

The inequity these reforms intended to address will not disappear. The sector will have to engage proactively in the new Government’s priorities, specifically over the adopted FYFV and devolution and integration. The sector must then use them as a platform to build a more sustainable future. The Government’s commitment to £8bn extra funding for the NHS underlines the necessity of this approach.

This paper is an interesting addition to the FYFV’s New Models of Care. It makes a compelling case for separating clinicians, with generalists leading an integrated community service in larger centres. Specialists would be freed up to work in fewer ‘centres of excellence’. This deserves to be explored alongside others. However, reorienting local health systems toward care at home and marrying health and care, with such fundamentally different structures, is a huge challenge, not least given (often politically motivated) hostility toward reshaping acute services. As recognised, the ‘how’, shared IT systems, constructive conversations with local communities at their centre and the building of something approximating consensus, is often as difficult as the ‘what’.

Overcoming these challenges has never been more pressing to improve people’s experiences and outcomes.

Patrick Hall, Practice Development Manager (Policy), Social Care Institute for Excellence  

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