Readers' letters - 26 April 2012

Shared mission

In Paul Corrigan’s article on integration (opinion, 12 April, page 18) he calls for an “integrator”. We have one. It is each local authority’s health and wellbeing board. Here is the chance to integrate “health” and “wellbeing” into one rounded offer, bringing together elements such as education, employment, environment and housing as well as health and social care. That offer can be tailored to individuals as well as to the population as a whole.

Some embryonic health and wellbeing boards, such as Croydon’s, are already well into it. They have taken this chance to integrate the understanding of health needs. This joint understanding should lead directly to an integrated strategy for health and wellbeing, to which all participants can sign up, based on public health outcomes that have recently been refreshed. Crucially, this sets the framework for integrated commissioning that Corrigan calls for. To understand commissioning, say it slowly: “co-mission-ing”. The shared mission is to achieve health and wellbeing. Delivery of caring services is just a subset of that common purpose, and must not detract from investment in wider determinants of health, or from helping people help themselves. It is perfectly possible to integrate a plurality of providers, provided the mission is clear. It does not matter (in fact it helps) if general practitioners sit at the health and wellbeing board as both commissioners and providers. And, to round off their integrative role, the boards can conduct integrated scrutiny into all parts of the system, to see if collectively and individually the parts are delivering the agreed objectives, and within budget.

Integration does not mean centralisation or conformity. The whole point of local authority leadership and accountability is to find local solutions to local needs within local resources. Those resources include local people themselves - patients, carers and communities. Integration means interdependence. integration requires collaboration. Commissioning is not something you do to a provider, it is something you do with a provider. There are obligations both ways. There has always been, and always will be, elements of choice, competition, affordability and political upheaval in the NHS. These are not the enemy of integration. The main obstacle to integration has been the inappropriate zeal with which a tariff-based system of episodes of acute care was imposed on the NHS, in haste, without the counterbalance of tariffs for preventive work, community care or mental health, or the involvement of social care. So the system rapidly fragmented (“dis-integrated”) and costs ran out of control. No one was doing prospective programme budgeting - they were merely responding to demand.

For the integrator that Corrigan calls for, and the integration we all call for, we should commission for programmes or patterns of care. How the providers are paid - by tariff or block contract, activity or outcome - is a secondary issue and should not be the driver. So, health and wellbeing boards, it’s over to you.

Dr Peter Brambleby, independent public health consultant