Rising demand, increasing financial pressures and the need to modernise care services, little wonder that the integration is regarded as a panacea. Integration has risen rapidly to the top of policy agendas. Heralded as a key approach to tackling demand and finances at the same time as delivering seamless services and joined-up care, on the face of it, such ambitions are to be welcomed. However, scratch beneath the surface and the commissioning and delivery of integrated services is not the simple cure-all it initially seems.
Alongside primary health, public health and the third sector, care providers are a key pillar of community services. Yet integration is often viewed short-sightedly. It is usually framed vertically within the NHS, or at best, between the NHS and local authorities. There is an absence of independent care sector voice and experience in delivering integration, and this risks compromising efforts.
Take the state of the transforming care (or the Winterbourne View) programme. It was set up to move people with complex needs out of institutional assessment and treatment units and into community provision. The programme follows a series of earlier initiatives that failed to deliver the change required.
It is still failing to engage with providers who are ready to help with the transition. NHS England commissioned Stephen Bubb, Chief Executive of the Association of Chief Executives of Voluntary Organisations, to review the stalemate. His report, Winterbourne View – time is running out, describes a need ‘to move beyond the walls of the state – providers, individuals and local stakeholders must be brought in as equal partners’. These observations get to the heart of the matter – from Winterbourne View, to winter pressures or any of the pinch points currently being experienced at the health and social care interface.
The recommendations of the Barker Commission provide long-lasting solutions to the challenges of integrating budgets. It recommends the move to a single, ring-fenced budget, with a single commissioner. We also know that integration is as much a cultural challenge, as a financial one, for organisations to come together and collectively focus on population health and wellbeing.
What needs to change?
We are at a crossroads. The state of funding in the sector is bleak and, as a consequence, the risk is that the entrenched positions of commissioners and providers will intensify. Opportunities lie in workable solutions that build on good practice and are ‘win win’ for service users, providers and commissioners across the system.
We need to take the long view because as austerity continues to bite, the ‘here and now’ preoccupies policymakers, commissioners and providers. Being clear on our long-term ambition is essential to securing sustainable growth – whether from investors, commissioners or providers. This needs to be done in the round, because with around 400 separate commissioning organisations working across a host of markets, fragmentation is a critical issue impeding integration locally.
Social care needs to start talking the language of the NHS. The NHS Five Year Forward View offers an important opportunity to seize the benefits of integrated care. Care providers have a record of innovation and enterprise and are an integral part of the solution to joining-up local services to improve outcomes.
Providers can put people and co-production at the centre of care delivery. They can help to make connections between local services and to build community capacity, such as volunteers, that are at the heart of caring and economically prosperous communities. Providers can do more to articulate the case for social care investment in the local NHS, including increasing the evidence base for what they do. By doing so the sector will become an attractive proposition to clinical commissioning groups.
Integration is no quick fix to underfunding; it is more nuanced than the headlines suggest. But the approach, with the accompanying pooled resources and shared risk, does offer an opportunity to rebalance both the health and care systems. The focus is welcome, as is a more subtle debate, because continuing as we always have, caught up in silos, is no longer affordable and does nothing to encourage the innovative and sustainable approaches that both health and social care desperately need.
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