Care and health integration

Two of the publications featured on CareKnowledge this week look at the subject of integration. It reflects on where the integration agenda is going, North and South of the border, and on some of its less fully obvious – and possibly more problematic aspects – including its effect on children’s services:

The two specific reports that triggered my interest came from:
• The Centre for Workforce Intelligence and looked at some of the options for integration and their workforce implications in England;
• The Institute for Research and Innovation in Social Services, in Scotland, which distils the key findings of research to assist health and social care partnerships in Scotland in their delivery of integrated care and support.

A feature of both of these reports is that they have to confront the reality that, at the moment the precise form of integration chosen, in England and Scotland, will be subject to considerable local discretion.

Things are tightening in Scotland, as the Public Bodies (Joint Working) Bill makes its way through Parliament, and some national requirements are more fixed than they are in England, but, on current plans, there will still be some scope for local health and social care partnerships to pursue somewhat different models of integrated working.

In England, the exact nature of fuller health and social care integration will only emerge after the next election – although we already know all main parties are committed to further action of one sort another. The core policy that is driving development at the moment is the Better Care Fund (previously the Integration Transformation Fund). Under a set of wide targets, and a single financing regime, that again leaves much to be determined locally, about exactly how better integration will be delivered.

The Centre for Workforce Intelligence’s report perhaps best illustrates the continuing multi-choice aspects of local integration. It begins with an analysis of four options for integration that it says need to be fully understood, because the workforce implications differ in each case. It also suggests that a blended model of options may emerge, again complicating the workforce picture.

That set me to thinking that the same is almost certainly true for all of the other aspects of integrated working that will need to be negotiated. The exact option chosen locally will have direct implications for all of the operations of the partnerships involved and, assuming continued local discretion in the models adopted, that will theoretically mean different local solutions for integrated IT, buildings and accommodation, policies and procedures, and for everything that will be needed to make local integration work.

Is all of the above a problem? Perhaps not – if you have a real belief in local discretion and accountability. And certainly not if you believe the best care outcomes will be delivered by that diversity. However, it also means a fiendishly complex set of structures and service arrangements will be needed from a national perspective, and it will make it much more difficult to meet the strong public desire to know how services are performing nationally. Additionally, allegations of post-code lotteries may become more difficult to deal with.

Anyway, the next few months and years will show how much diversity governments will be able to tolerate, but there were two other straw-in-the-wind that the new reports brought to mind. One was that the integration agenda is almost entirely focused on adult services. In Scotland, the initial plan was for an even more specific focus on older people. So, what are the implications of all of this for children’s social care? And just how far are we accelerating away from the notion of whole-family focus originally embedded in the creation of social work and social services departments?

And, for England at least, what might the roll-out of the Better Care Fund be telling us about what a more integrated future might look like? Major elements of the fund come from the NHS budget. The fund has to be jointly spent, and comes with conditions that focus, to some extent, on high-level health and social care need which, given LA cuts, is likely to mean that little will reach those with lower support needs or preventive services.

Finally, for this blog, we need to recognise that NHS funding for the Better Care initiative is coming from their nationally allocated pot. Being the NHS, I’m sure there are other things they could have spent the money on. And being the NHS, I’m sure they will have had to look at other programmes and plans to find that money.

I’m not saying that there is any direct connection, but it’s interesting that, in the same timeframe as the government has been working to redeploy resources into integrated care, NHS spending on mental health services is said to have fallen by a total of about £300m (the NHS contribution to the Better Care Fund is £1.9bn) over the past two years, which may just be a further indication of how difficult it will be to protect any services in new integrated arrangements – whatever their local form – that don’t look like immediate life-or-death priorities.