Local Authority and NHS Integration: another lost opportunity? GERALD WISTOW HEALTH AND SOCIAL CARE INTEGRATION IN THE NEW POLICY LANDSCAPE SHA/SPA SEMINAR Y O R K U N I V E R S I T Y , 1 2 TH O C T O B E R 2 0 1 2
Outline What is the problem? How do we recognise it? Does it matter? Everything‟s going to be different now, isn‟t it We understand the problem and know what works now Face the facts, it‟s never been fixed in over 50 years We‟re trying the same old solutions……. And the new landscape is a large part of the problem We might be forced to find a different way…..
If integration is the answer, what is the question? How do we achieve better outcomes and experiences for people whose needs span different professional and/or organisational boundaries? What kinds of care and support models will deliver such outcomes and experiences and for whom? Who is responsible for ensuring the delivery of those outcomes, experiences and services and how are they held accountable? What are the implications for national hierarchy of a commitment to strengthen local networks?
Integration todayWhile many people told us of excellent care, we heardalarming stories, particularly from the mostvulnerable, of poor access, falling through gaps betweenservices and being unable to understand how to navigatetheir way through the convoluted „system‟. We heard frompeople who had experienced delays and come to harm.The universal feedback was that the current system isfragmented and all patients, regardless of theircircumstances, want a more joined‐up and integratedhealth and social care service, planned around their needs (Field 2012 p.9).
Integration today„Sadly……..we have been told repeatedly that the system, asit stands, often does not deliver the integrated package ofcare that people (with complex problems) need. It doesn‟tdeliver their desired outcomes either………There are oftenwide gaps between services…. The often inefficient andunreliable transitions between services result induplication, delays, missed opportunities and safetyrisks…………and we know the recent scandals inhospitals, home care, and care homes will not go away if wedon‟t change the way the system works.‟ (Integration Future Forum 2012)
Integration today „the development of each service was usually considered in isolation, and it could not be said that there was an overall plan for the development of services for (older people) in any of the authorities studied‟ The local authority associations …….warned that if they were not able to meet the extra expenditure needed to expand their services, the Minister‟s hospital plan would be imperilled‟
Integration Todaythe document frankly expressed the rising tensionswith local government over what the (SHA) claimedwas ‘bed blocking’ and the ambiguous statusof………….‘large numbers of relatively activepatients’ (who) were occupying beds ‘which areneeded for the admission of urgent cases’ due tofailure to provide suitable accommodationelsewhere. . .. Gorsky 2012
We need it even more today Less hospital centred care and support systems with proper investment in community networks and informal care, together with shift to prevention, early intervention, wellbeing and independence Social determinants of health: causes of the causes Strategic commissioning: address Dilnot‟s suboptimal balance of national spending; service re- configuration; reduced support costs; shifting responsibilities and resources Personalised commissioning: choice, control and joined up services from community and personal budgets
Everything will be different now….. Enhance role of local government in health and overcome NHS „insularity‟ by leading on local health improvement and prevention (DPH) joint strategic needs assessments (JSNAs) joined up commissioning of NHS services, social care and health improvement through HWBs and JHWS Strengthening local voice Transfer of £7.5bn from the NHS to councils over four years to help NHS meet the „Nicholson challenge‟. £2bn pa to fund LA public health functions Introduction of stronger LA leadership role and more local democratic accountability for first time since 1948
…….or perhaps it will be the same? Long line of initiatives to design new frameworks for integration, each beginning with recognition that the last had limited results „Despite repeated attempts to “bridge” the gap between the NHS and social care……..little by way of integration has been achieved over this 40 year period‟. Some success: contribution to closing long stay hospitals and creation of islands of good practice often despite „the system‟ Can the latest statutory framework succeed where others didn‟t?
Do we ever learn?In all the debates about reorganising the structures ofcentral administration, local government, healthservices, social services and finance, the first need is todecide what it is hoped to achieve by the changes to be made.Then and only then, can useful discussion take place on howto achieve it. If it is hoped to achieve more effective planningfor the health and social services it is doubtful how farstructural changes of the kind being discussed will help toachieve this aim. Sumner and Smith
The collaboration paradigm Statutory duties to work together Coterminous boundaries Coordinating structures producing joint plans Financial incentives Permissive powers and limited accountability Bridging organisations rather than integrating mainstream businesses Means not ends, structures not cultures
What helps? No silver bullets (but plenty of fool‟s gold) Knowing the question before the answer Common purpose before structure Outcomes before mechanisms Structure and agency Relationships and time Local and national leadership and accountabilities Power to move resources as well as technical competence
Time to Face the Facts? Consistent weaknesses raise questions of systemic failure and fitness for purpose Implementation deficiencies or flawed design? Both: institutions of structure, process and culture create the spaces within which implementation is conducted with more or less skill, creativity and commitment Those institutions, in turn, are rooted in decisions at foundation of NHS and 1974 reorganisations Institutions of NHS and local government designed to be different and separate not similar or integrated
……… but we always knew it was sub optimal Organisations primarily based on „Skills of professionals not needs of clients‟ A place, local variety and functional coordination The service, national uniformity and functional specialisation Coterminosity „an attempt to get as near as possible to the advantages of…..unification by creating “two parallel but interacting structures” (Joseph) A „miserable middle way‟ (Crossman) Need outward looking „community governance‟ (Stewart)
Opportunities Lost Re-assurance about competition and markets The Treasury and Management win the battle for credibility and control The NHSCB re-centralises with commissars for every CCG HWBs as a crucible for integration but not the location for system leadership and steering (the „guiding mind‟) If agreement is not possible at the HWB? Existing arrangements are disrupted and dismantled CSOs are service not place based Is it really possible to strengthen vertical and horizontal accountabilities simultaneously?
The source of continuing problems?GP consortia, working individually and together, willprovide the engine for the commissioning systemlocally, assuming statutory responsibility forcommissioning the bulk of services.Consortia will need support and direction in order tocarry out this critical role effectively and providing andshaping that support will be the central role of theNHS Commissioning Board.The Board will be confident about leading change atscale – not through top down diktat, but neither beingshy about claiming a leadership role.
Different options emerging Single accountable officer: Health Committee and Scotland Part of CCG budgets lodged in LAs Integrated purchasing through LAs integrated providing through FTs (Burnham and SHA) Place based, community budgets Coordination through market mechanisms NHS as LHS: less insular, playing a fuller part of the local family of public services or a single- purpose, nationally controlled service;