Structural change alone will not be enough to ensure integrated care improves outcomes and makes services more financially sustainable, says Alex Khaldi
The health and social care integration debate has reached a significant fork in the road. No, it wasn’t the latest iMPOWER report, although it does frame this juncture quite succinctly.
Rather it was the local government minister Stephen Williams MP who, for the first time for a minister, publicly and clearly linked integration to cost reduction and savings.
‘Making behavioural change a significant part of transformation will be the difference between success and failure’
Within the health and local government families respectively the integration question has, of course, been in the context of downward spending pressure; however, the public discussion has singularly focused on quality of care and outcomes. Not any more.
In arguing that integration should allow public agencies to “deliver substantial savings towards meeting their budgetary obligations”, Mr Williams is forcing everybody to stare down the elephant in the room. The integration of health and social care needs to make it cheaper to deliver care and improve its quality.
The big danger our report, A Question of Behaviours, flagged up was that without addressing the behaviours and relationships of citizens and professionals, alongside big structural and system changes, we would fail to integrate care effectively, neither improving the quality of service nor having the necessary financial impact.
During the six months of research that went into the report, it became clear that trust, relationships, behaviour and experience are the real drivers of positive outcomes. Currently the behaviours of many patients, users and professionals create perverse outcomes for them and the system, driving up demand and cost.
Lack of trust
Take, for example, our finding that more than half of GPs (56 per cent) find social care in their area either poor or very poor, or that just under half (47 per cent) do not trust hospital discharge teams to manage care effectively. This fundamental lack of trust is shaping behaviours.
Look at the referrals of older people to residential care as opposed to using telecare. When probed further, more than half of GPs (57 per cent) said they did not believe telecare was an option in their area, despite the vast majority of adult social care directors interviewed being incredibly proud of their area’s telecare offering.
This is not just about better information sharing; this is about better relationships. Nor is it just about professionals. Patients and users play a big role too; their behaviours and attitudes matter a great deal and when only 46 per cent of older people are confident they know how to access the health and care system we can start to understand why Sir Bruce Keogh noted that about 40 per cent of accident and emergency attendances require reassurance rather than treatment.
‘The argument is not that structural change is bad, just that alone it is insufficient to the challenge we face’
The rationale is clear: to simultaneously improve outcomes and make services more financially sustainable, making behavioural change a significant part of transformation will be the difference between success and failure.
There is £3.8bn allocated to fund integration and additional resources continue to be poured into overstretched urgent and acute care. The risk is that this money will be used to fund yet more structural change, which cannot succeed without the real behaviour change of all actors in the system.
The argument is not that structural change is bad, just that alone it is insufficient to the challenge we face.
Alex Khaldi is managing director of iMPOWER