Future obstacles in the race for an integrated health and care system

Obstacles remain in the desire to move to a more integrated and prevention-oriented health and care system

In a speech in March, Health Secretary Sajid Javid pledged to improve preventive care. “Not only do we need to put the power of every part of the NHS behind prevention, but we also need to put the power of the NHS budget behind it,” said Mr Javid at the Royal College of Physicians.

The health secretary’s focus on prevention was welcome. As Professor Sir Michael Marmot, Director of the UCL Institute of Health Equity, pointed out at the Association of Local Government/Association of Directors of Public Health conference last month: “We were not in very good health as the pandemic approaches…we need to restore the capacity of local government to act and deal with the fact that we were not in very good health.

But Mr Javid’s speech made only one reference to local authorities, the guardians of public health, and the term ‘public health’ did not appear there at all.

As Mr. Javid acknowledged, there is a strong link between prevention and service integration work. The February integration white paper states, “Done well, integration will enable a concerted and collaborative effort across the health and care system to close the disparity gap and improve population health.

“We need to restore the local government’s ability to act and deal with the fact that we weren’t very healthy”

Sir Michel Marmot

The long-standing hope, in local government in particular, has been for a widespread shift in spending and prioritization of treating the disease towards preventing it in the first place. Public health’s 2013 shift from the NHS, where it was widely thought to have been neglected, to guidance sought to facilitate this. Investing in areas such as housing, recreation and social services can improve people’s health and prevent disease – and councils were best placed to lead.

Despite the good intentions of successive governments, mainstreaming approaches have so far not produced the expected results. The problem has been compounded by the impact of austerity on overall council budgets and the reduction in real terms of the central public health grant.

Below ambitious targets

The December Nuffield Trust report, Integrating health and social care: A comparative of policy and progress across the four countries of the UK, reports only “modest improvements” on issues such as healthy life expectancy and patient satisfaction, raising “important questions about what integrated care is”. can really deliver.

“Politics has always attached very high ambitions to integration,” report co-author Sarah Reed, senior researcher at the trust, told LGC. “He has very high expectations of what he can accomplish in terms of reducing costs and improving service efficiency.”

A lot of it is about shifting the focus to make sure it’s in the right place on user experience and service delivery, she says.

“Policy tends not to be effective when you focus on cost as the main objective or outcome. If the starting point is to cut costs, we won’t get very far, and that could skew things towards the wrong places, because what is best for patients or service users often does not improve efficiency.

Local Government Association deputy chief executive Sarah Pickup agrees.

“If it’s about real integration, it’s about helping people get on with their lives”

Sarah Pickup

“If it’s about real integration, it’s about helping people get on with their lives,” she says. “Some of these measures are not services to individuals, they are community-based.”

“You have to start with the communities,” says Paul Najsarek, social services spokesperson for the Society of Local Authority Chief Executives & Senior Managers.

“You have to start outside the [health and care] system to be most effective. You have to take care of jobs and housing, income etc and more often than not the councils do a great job in our space but this is not always designed as part of the health and social care program .

Hierarchy of local needs

The Integration White Paper released in February by the Department of Health and Social Care and the Department of Leveling, Housing and Communities was intended to emphasize place in the health and care system. The NHS has traditionally been hierarchical, with agencies constantly seeking the national chain of command, rather than focusing on specific local needs.

The first line for local government was the recommended creation of “place committees” to sit within integrated care systems and be led by a single responsible person. By spring 2023, all SCIs must adopt this model or an alternative that achieves the same objectives.

Place councils are to be assembled by a region’s integrated care council and its council, bringing together partner organizations to pool resources, make decisions and conduct joint planning.

“The white paper gives venues enough flexibility to land in a way that makes sense to them”

Paul Najsarek

Council functions and budgets will be jointly delegated by the council and the ICB, and will oversee the commissioning and funding of primary and community care services, mental health services, adult social care providers, hospitals and other health care services. The single responsible person will be responsible for the delivery of the shared results.

“The responsible single digit is useful,” says Mr Najsarek, the former head of Ealing LBC. “The white paper gives venues enough flexibility to land in a way that makes sense to them.”

But, as Ms Pickup points out, it is essential that the detail of what exactly falls under their responsibility is properly defined and made clear to all partners.

“You have to know how you’re going to make decisions, particularly whether you’re going to take the resources you have and use them in the best way for local people when you have these very different lines of responsibility between councils and the NHS,” says- she.

But who should do the work? And what should the role look like in practice?

“Ideally, you would select skills, not role,” says Najsarek, “because there are different roles that could do that. With my Solace hat on, a CEO of a strong local authority is wise for the role.

Even if the role is not filled by the head of the council, Mr Najsarek says that “creating a strong connection and accountability to the chief executive is helpful”.

Along with accountability comes funding, he says: “More [the single accountable figure] has direct responsibility for the budget, the more you can create the conditions where they have sway over key institutions in the locality.

Clear direction

Ms Pickup warns that while pooling funds is ultimately beneficial, it must be accompanied by clarity of substance and direction: “You need to be clear about what funds you are pooling, what you are looking to achieve with and who is responsible for achieving it.

“It’s a bit like when you take a contract, you know that you are ultimately responsible. You ask someone to deliver something. If they don’t… you can hold them liable under the contract.

“You are ultimately responsible for your citizens not receiving the services you ordered for them.”

The road to integrated services has been a long one, with a series of green and white papers and legislation over the past 20 years promising a revolution that would lead to more people-centred services, less duplication and greater concentration. on prevention. Although the pace of change has been slow and hurdles remain to be overcome, it is clear that the financial incentive and will of system leaders remains to bring about this revolution.

The story of care: how the system was created and reshaped

National Health Service Act 1946
Hospitals, doctors, nurses, opticians and dentists came under the NHS, which came into existence in 1948. However, services were divided, with local authorities responsible for community services including vaccinations and community nurses .

Health and Welfare Act 2012
Health Secretary Andrew Lansley’s reforms have led to a fragmented and complicated system in which clinical commissioning groups led by general practitioners have commanded local health services. It was generally believed that the development of a market had taken precedence over the integration of services. At the same time, public health has shifted from the NHS to the councils.

NHS Long Term Plan 2019
In response to the fragmentation of the Lansley reforms, this required the whole of England to be covered by integrated care systems. The Health and Care Bill, currently pending in Parliament, proposes to enshrine them in law.

White Paper on Social Protection 2021
This is the latest in a long line of government documents proposing to place service users at the heart of their care. However, industry executives said the target was likely to be jeopardized by financial and labor shortages.

White Paper Integration 2022
This gave details of the governance of the integrated system with an integrated health and social care board operating at a ‘local’ level, more localized than the ICS as a whole. At this level, a single chief would be responsible for all services and resources could be pooled. The place council would be assembled by a separate integrated care council, which will oversee the commissioning of services.

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