Integrated care is the ingredient that can bind health and social care players to achieve real integration, writes Charles Alessi.

The delivery of healthcare is changing all over the developed world. The drivers associated with this change are well documented, from ageing populations to increased complexity of concurrent morbidities.

However, there is another factor at play here and this is the inevitability of managing the funding of a service when the financial environment is adverse and likely to remain a real challenge. 

Do we spend enough on healthcare in the UK? The disparity in funding is stark and it is acknowledged that with an annual per capita spend in 2009 of around £1,900 we are one of the most modestly resourced countries in the developed world.

Figures from the NHS Information Centre have also alarmingly revealed that spending on primary care last year fell more quickly than expenditure in the rest of the NHS.

This is a significant challenge in the context of increasing and welcome responsibilities around clinical commissioning

Part of the difficulties we face is the fragmentation of services for patients between health (as well as social care) providers as well as the disconnection between clinical behaviours and their fiscal consequences.

It is obvious that by integrating services and functions we can not only lessen duplication, but also offer the patient a better connected journey through the system.

We all live in a universal state funded system for the delivery of healthcare. As practitioners working within this system we must acknowledge that we have fiscal responsibilities for the populations we serve and that part of our responsibility is around the prioritising of care within that budgetary constraint.

Some clinicians feel they need to remain untainted by any involvement in the prioritisation of decisions within our limited resources. I would suggest that given a choice, all of us would prefer to be allowed to practise our craft without any fiscal context.

Unifying purpose

However, if we operate in a system which has financial boundaries, I believe it is an abrogation of our responsibilities to patients and populations if we do not involve ourselves in decisions to maximise operational delivery of care.

Wellbeing and commissioning is about more than healthcare. It is about the health of the patient and the citizen and their families. Therefore it includes much more than the medical and health interventions and thus the role and active involvement of the local authority is going to be a key determinant of success. 

Clinical commissioning groups face a difficult future with limitations around the management infrastructures, so clearly there is a place for integrating services to provide efficiencies. The trend seems to be to move to a vertical integration around clusters and this may well be required on occasions but should not be the default option.

If population health and place is what the thrust of the changes is about, would not integration with the local authority be more appropriate? Would it not encourage the integration of care at a local level and the start of some genuine co-commissioning between health and social care?

The term integrated care is rightly felt to be the place we should aim for both within health and with local authorities. However, integrated care is more than increasing efficiencies, and reducing duplication. It needs to signal that health and social care should move in a direction with shared values and purpose.

This unifying purpose is the optimal delivery of health and social care to a population. This gives a purpose that all players can sign up to and starts to break down the sterile arguments between primary and secondary care. An added advantage is that this approach gives the prevention drive– which we have ignored for so long – the oxygen it needs to demonstrate it can deliver the medium-term savings it has always shown the promise to deliver.

Clinical commissioning groups need to be nurtured through the transition. Nurturing does not necessarily translate into limitation of flexibilities and an acceleration of the process of accountability and assurance. The nature of commissioning support through this transition is likely to be a key determinant of success. We have a way to go before these organisations start to understand their roles and relationships to clinical commissioners are at least as important as their relationships to trusts and clusters. 

Population health is our future. If we accept that all sectors of social and healthcare including foundation trusts are tied into a system with finite resources and we all acknowledge that we have to live within these confines, we will be in a better place to discharge our responsibilities to our populations.Then, perhaps, our much-loved NHS will become far more sustainable in the long term.