The many questions we still need to answer on integration
Integration: what does it mean to you? For some it is an antidote to the evils of competition, for others a way to create a sustainable future for shaky organisations.
For many integration is the only way to deliver truly joined up care; for an increasing number of people it is the silver bullet to break down the decades old institutional barriers between health and local government; and for some it is the next model to be imported from overseas to retrofit the “out of date” NHS.
The King’s Fund and Nuffield Trust have been commissioned by the Department of Health to “help support the development of a national strategy for the promotion of integrated care”. The NHS Future Forum’s latest task is to examine how the idea can be adopted more widely. Meanwhile, Monitor, sniffing the prevailing policy wind, talks openly of “competition-free zones” and “safe harbours” to allow integrated models to develop.
It seems that whatever the question or issue, “integration” is the answer.
But what sort of integration: vertical integration between primary and secondary care, horizontal integration between health and social care, even between commissioners and providers or all three? Need integration be delivered by organisational merger or pooled budgets? Or can it be provided by that most hackneyed of phrases, “joint working”, or plain and simple cooperation?
Can integration only be delivered by the public and third sectors or does the private sector have a, maybe significant, role to play?
Are the not-for-profit integrated care operations, all the rage in the US, the right model or is it social enterprise? Anyone had a look at Finland, Sweden or Spain? Almost every approach has some high profile fans.
And how much does the NHS need to re-engineer its incentive structure to make integration, whatever it is decided to mean, happen?
The flagship local government “whole place” initiative to build “community budgets” is tip-toeing around the integration of health services. Social care minister Paul Burstow told a recent King’s Fund meeting that many in the public sector thought it was too “risky” to integrate services.
Does the behaviour encouraged by payment by results provide an insurmountable barrier to integration? Will the any qualified provider policy fragment provision to the extent that integration is impossible or will clever clinical commissioners and their support organisations use their muscle to stitch together integrated networks that deliver choice and consistency as Charles Alessi argues?
We can look towards the South West for the answers to many of these questions. The region has gained significant autonomy by performing ahead of the curve and showing little tolerance to financial indiscretion. This has fostered a culture of innovation. Indeed, the South West already possesses the poster-boy for NHS and social care integration, Torbay and Southern Devon Care Trust.
Like all health economies it has its challenged organisations, but our story on the future of Weston Area Health Trust shows the wide range of innovative solutions being considered.
There are, of course, other sites of emerging integration throughout the NHS. Weston, for example, is examining the model being rolled out in Herefordshire’s Wye Valley.
But a note of caution is needed. Integration will not prove the panacea to all NHS ills. The sometimes contradictory and destructive nature of the reforms is throwing any kind of supposed alternative into an unrealistic golden light. Services can be “integrated” for a wide range of motives – not all associated with improving public health and wellbeing – and with varying degrees of effectiveness. This danger is especially great in a period when money is tight.
Before the NHS moves forward we will all need to learn the difference between good and bad integration.
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Readers' comments (10)
Jules Acton | 26-Oct-2011 2:06 pm
Good questions. National Voices describes what good integration might look like from the patient's point of view. This is set out in our Principles of Integrated Care, launched yesterday.
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Anonymous | 26-Oct-2011 3:10 pm
Where is the evaluation of the national ICO pilots ?
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Blair Mcpherson | 26-Oct-2011 4:15 pm
Ask anyone in Social Services and they will tell you integration is the creation of seamless health and social care services and the removal of duplication. We often fail to recognise that a lot of energy is being expended trying to get coordination and cooperation between Acute Hospitals and GP practises, Acute Hospitals and the Ambulance service, GP practises and Mental health Trusts. No wonder there is little time and energy left for the small poor cousins that is social services.
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Mark Cannon | 26-Oct-2011 5:58 pm
I agree that the National Voices Principles for Integrated Care are solid, particularly that care must be organised around the needs of the individual. Understanding the purpose of the system from the users perspective reveals profound but simple things that can be done. At least that is what I have found (http://goo.gl/26lL2). When looked at like this, the way we define integration (in relation to health and social care) is too narrow. We seem addicted to doing things in the name of efficiency that make things worse though. As your questions show, the system gets taken further away from understanding people in the context of the way they live their lives, not closer to them.
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Anne Tofts | 27-Oct-2011 12:37 pm
The 'Total Place' pilots provided some useful learning on effective integration and the levers that supported innovation and real improvement and change 'on the ground' - where has that learning gone and how are we integrating it into CCG development?
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Anonymous | 28-Oct-2011 1:08 pm
It is worrying that we are always scrabbling around for a panacea to "modernise" the NHS. We seem to go round in ever decreasing circles. Torbay Care Trust has been around for while, if its so good, why isnt it the standard model already ?
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Jeff Featherstone | 28-Oct-2011 3:22 pm
A key problem is that all too often integration is seen as a provider issue whereas it is integration between health and social care at the commissioner level that is needed to bring about leadership for real change.
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Jonathan Spencer | 1-Nov-2011 10:41 am
An interesting article, but having just come across the HSJ online. Having worked in the public sector and private sector in both health and social care, I am still astounded by the powerful vested interests in healthcare that say the word patient when they are really talking about their own powerbase or interests.
I am not surprised to see the whole NHS reshuffle itself (after a suggested revolutionary change) back to what its always been.
Integration is about giving away power. Fine in Torbay but in population dense areas like London and the home counties it is high stakes health service politics.
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Anonymous | 2-Nov-2011 9:37 am
(Copied from Rosen 24/10)
"Trouble is people are using the common dictionary use of words like integration, partnership, cooperation and a hundred collaboration-type phrases as if they all mean the same squidgy thing. We did the same with commissioning, contracting, procuring and purchasing and found out later they were different.
There are already some well evidenced methods of working together differently with integration between practitioners, partnerships between stakeholders with a common interest and cooperation between organisations that don't trust each other.
Leutz (1999) description of integration levels from linkages to coordination and on to full integration, is described as the first law of integration: “you can integrate all of the services for some of the people, some of the services for all of the people, but you can’t integrate all of the services for all of the people”.
It's a common finding that the more formal the method of working together the more fragile the relationship."
Blair's right ... ultimately "integration" is being used a word to mean removing the fragmentation that the Bill is going to exacerbate.
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Caroline Mitchell | 3-Nov-2011 2:08 pm
If you look at comparisons between Obama's Affordable Care Act and ACOs and here the Bill and CCGs and integration, the similarities are significant (probably copied across the ocean by a well known Consulting McFirm). My fear that there is 'lazy thinking' and a lack of what I call 'operational discipline' - the ability to turn strategy into reality and everyone seems to be rushing down the so-called integration route without any understanding. Managed care, medical home and other concepts have been tried in the US with pockets of success. Are the vested interests too big to overcome? If you do what you have always done, you will get what you have always got.
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