News and Comment

How can we make integrated care affordable?

Tuesday 27 August 2013


Integrated health and social care was the hot topic at this year’s LGA conference. The government announced plans! Labour announced plans! the LGA announced plans!

Pioneers are to be established. Pilots are to be set up. In the face of a demographic time-bomb and cuts in social care – integration is everyone’s solution.

But we also have learnt the hard way about what happens when carefully designed, locally adapted, well-led experiments are ‘rolled out’ to places where none of the right starting conditions exist. There are no ‘magic bullets’ here and suddenly everyone is peddling computer systems, risk-stratification models, IT integration packages, project management systems, pathways diagrams….

And there’s a bigger issue… we know from the evaluation that has been carried out of all the pilots so far, that while integration is popular with both clinicians and with service users – it hasn’t reduced unplanned or emergency admissions to hospital. The savings haven’t yet materialised. Now this may not be a problem in the long-term. Most system redesign experiments fail to work well at first. But what if the system pressures are strong enough to prevent savings being made?

As always, the devil will be in the detail. But there are some important lessons from previous ‘whole system’ change such as Total Place and Community Budgets which helps to inform the work that OPM is doing in a number of places making health and social care integration work. These include:

  • Without firm, skilled system leadership, organisations won’t be able to make new arrangements stick.  The shared sense of purpose is critical – and the agreement to make life better for service users.
  • Commissioners and senior managers are too far away from what really happens to know what will and won’t work. It’s the users, the GPs and the front-line staff that need to co-design new ways of working.
  • Just because a system has been designed to function in a certain way, there is no guarantee that it will. Most system failure happens because people don’t behave in the way that the system engineers intended. They’re not components, they’re people. Winning hearts and changing mindsets is more important than drawing diagrams.
  • Unless the whole system is part of the change – people will fall through the gaps. For example, unless the out-of-hours GP service is connected into new arrangements – they will continue to call ambulances and send people to A and E in the middle of the night!
  • Different players in a system need different results – and the most successful change may involve navigating between the different needs of users, clinicians, acute hospitals, social care providers – system leadership is making sure everyone stays on board so that plans turn into action. That means making the time for leaders to come together to understand and reconcile their different perspectives.
  • The most ambitious, comprehensive approach may not be the most effective. Some obstacles can be worked round. Start small and follow the energy. Find the people who want to make it work and liberate them. Demonstrate success – and learn from it. It may not be necessary to invest millions up front in new computer systems and new organisations. What matters to the service users is practical change on the ground. It may not cost much.

As we implement exciting new preventative programmes, and experiment with ways to reduce hospital admissions, we also need to recognise that there are some longer-term, more fundamental issues to be addressed.

First, we need to think hard about who integrated care is for. Merging a universal health service with a means tested social care service raises important questions about the limits of state help. Trying to reduce preventative services to save money has resulted in growing demands on the emergency and acute sectors. What is the way forward?

Second, many would argue that cashable savings from the acute sector are not achievable. It may be possible to improve the quality of care, and user satisfaction, but without necessarily reducing the pressure on hospitals. Integration is about managing increasing demand, and given the growing population of frail elderly people and those with dementia, integrated care is unlikely to solve the financial problems of either local government or the NHS. So if it isn’t the ‘magic bullet’ many expect – we may need to be cautious about ambitious ‘invest to save’ plans. Cheap and practical solutions reduce the scale of up-front investment and make it easier to create benefits that offset costs.

Oh, and one more thing. There was a lot of discussion at LGA conference about the problem of young inexperienced care workers on zero hours contracts. We do know that only happy, unstressed, empowered staff will treat service users well. The Cavendish Report suggests that many care workers feel they are being asked to perform the tasks of nurses (and in some cases doctors) without adequate training. Until we make sure that  care workers themselves are cared for, properly trained, and truly valued, we are unlikely to create the care that you or I would want for our own parents.