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Integration a possibility or a pipe dream?

Integration is a hot topic, and has been for some time. Organisations across the sector are doing what they can to work more closely with health partners and there’s pilots-a-plenty experimenting with how health and social care can support each other. But without real action from the top, does integration stand a chance? Professor Martin Green OBE shares his thoughts on whether this system change is achievable in the current market.

Over the past few years, there has been a concerted attempt to talk about integration. Recently, this culminated in the Department of Health becoming the Department of Health and Social Care, but sadly we have discovered a change of name does not deliver an integrated system. We need to examine to what extent all the rhetoric about integration has been translated into practice.

In relation to the Department of Health and Social Care, the evidence is clear. They may have changed their name, but they have certainly not changed their spots. Since the announcement of a new title on the headed paper, we have seen the old practices rear their heads.

Several announcements have been made of huge amounts of money being offered to support the NHS, while social care received the announcement that the Green Paper was to be postponed. A few weeks ago, we had a ‘crumb from the table’ of an extra £241m for social care, but only on the condition that we can help the NHS deal with the self-induced delayed transfer of care crisis.

The hospital issue

It was very interesting to watch the BBC documentary, Hospital, about the Queen’s Medical Centre in Nottingham, which was dealing with significant issues around delayed discharge. In the programme, they never once reached out to residential care providers to see what they could deliver. Incidentally, Nottingham champions itself as a beacon of integration, but the documentary clearly showed that there was no sense of what could be delivered outside the NHS that could solve the problem. Finally, there was a scene where the room was packed with expensive managers, one of whom hung their head in their hands and issued the words, ‘We might even have to bring in the private sector’.

There was little evidence of an approach to integration in that hospital, only a focus on dogma and organisational myopia. One of the major problems which faces the NHS, is that its staff are often so blinkered that they think the only solution to anything is an NHS service, or more taxpayers’ money going into existing services.

Making it person-centred

Whenever I go to events and meetings that are about integration, there is much talk about organisations, systems, local authorities and very occasionally a word about the providers who deliver care, but I think this completely misses the point. True integration has nothing to do with organisations and systems, but it should be judged by the experience of people who use services.

The problem with our current approach to integration is that it is always defined by organisational goals and it is as if the organisation, rather than the citizen, is the objective.

The attempt to deliver integrated services is a very well-worn path, and I am old enough to remember many abortive attempts at integration.

We had local and health authorities delivering joint appointments, in the expectation that this would deliver better outcomes, more efficiencies and seamless services. There was also a move towards co-location of services, with the expectation that this would deliver better communication and more integrated outcomes. However, this too failed to live up to its anticipated success because, once participating organisations faced funding challenges, they retreated into their silos, rather than crafting an integrated and joint solution that would have been better for citizens and delivered more positive outcomes and efficiencies.

It is my view that we need to re-claim the word integration and set it firmly in the context of the experience of people who use services.

Learning from others

There are many examples of services which are delivered by a range of different organisations, yet are completely seamless when it comes to the experience of the customer. The airline industry is a really good example of this. I do not know when I leave Austrian airspace and go into German airspace, despite the fact that there is an enormous technical and managerial shift going on behind the scenes. What I experience is a flight from A to B, and I neither know, nor care, who is doing what in the background

The experience of the citizen has to be the ‘holy grail’ of an integrated service, and we must judge every service’s success not on its structure, or whether it is public, private or voluntary, but solely on its outcomes.

If we were really going to deliver integration, we would align the success measures of the whole system, focus them on the experience of the person who uses the service and, I think, we need to start using three high-level measures for success. The first measure should be person experience; the second should focus on the outcomes that are achieved; and for the third I think we need to question whether we are using our resources, both financial and human, in the most effective way.

To ensure we have a truly and wholly integrated service, we would inevitably have to start thinking differently across the whole of both sectors, and this would require some re-configuration of the current system and the decommissioning of some obsolete services, as well as a massive cultural change in the NHS and social care.

What about the politicians?

We are seeing a number of areas, such as Greater Manchester, attempting new approaches to integrated services across their respective cities. What is interesting to note is that, in all the discussions about reconfiguration and joint working, one area has been left completely untouched, and that is the local politicians.

It is frankly ridiculous to have layer after layer of local politicians who do not have the same outcome measures. We see it in London with local authorities, CCGs and the London Assembly, all working to different outcome measures and often in conflict with one another. We need to align these measures so that everyone is working together, towards the same goals.

Rhetoric or reality?

I do not believe that this rhetoric about integration will be delivered. What we will see is what we have always seen: tinkering around the edges, changes to the headed paper, endless amounts of money spent to move staff from one employer to the other.

And in the midst of it all, citizens getting fragmented and un-co-ordinated services from two systems that work on hugely different resource levels, completely disconnected outcome measures, and have no operational plan that will turn rhetoric to reality.

Professor Martin Green OBE is Chief Executive of Care England. Email: Twitter: @ProfMartinGreen 

What are your thoughts on integration? Do you agree with Martin that much more needs to be done before it can be considered possible? Share your thoughts and experiences below, where you can also feed-back on this article.


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