There is apparent agreement that there is a need to integrate all or at least some of the services, but there is a lack of intellectual rigour in facing up to the consequences of such a step, writes Paul Ridout

Integration dance cartoon

Historical reason for the distinction between health and social care provision goes back to the nationalisation of healthcare services in 1947.

Healthcare is provided free to all, irrespective of need, by a national agency, the NHS. Social care is provided by local authorities and is needs and means tested.

Increasingly, the distinction is criticised:

  • There are obvious similarities in services.
  • It is bizarre that financial contributions should be determined by analysis of need rather than personal wealth.
  • Local authorities have more constrained budgets (and indeed different priorities) than a national agency.
  • The twin system provides for two expensive bureaucracies, in many cases overlapping services.

The path to integration

There is apparent agreement that there is a need to integrate all or at least some of the services, but there is a lack of intellectual rigour in facing up to the consequences of such a step.

Integration follows a creation of a joint enterprise where parties bring together separate assets more efficiently to provide goods and/or services.

This usually occurs by:

  • the creation of a new organisation into which all separately held assets are injected; or
  • one organisation acquiring the assets of one or more others to create a larger organisation.

The path to integration may be preceded by experimental joint working to see benefits and challenges in practice before commitment to complex whole integration - merger or acquisition.

Joint working is a prelude to integration, not a form of integration itself.

‘Joint working is a prelude to integration, not a form of integration itself’

The most substantial obstacle to many mergers is the difficult decision about organising workforces, particularly at management level, and, identify of the leaders of the newly merged (integrated) organisation.

With public sector mergers there will be difficulties as to the allocation of powers which will nearly always require parliamentary legislation.

All the pre-election talk of integration in health and social care appears focussed on the preliminary pre-integration step of joint working rather than the bolder step of merger.

Even the Labour Party, which has argued for a National Health and Care Service, seems to have got some last minute nerves about advocating true integration.

The only realistic way to achieve integration is to achieve the considerable savings by bringing social care into the NHS to make a single service as suggested by Labour. Simple preliminary joint working, or worse, talks about joint working will cost not save money and deflect managers’ attention from frontline services to “integration management”.

Social services would need to be divested from local government and integrated, assets and workforce into the NHS. This would be most unwelcome to local authority social service departments but has many attractions and is the logical way forward.

The integration benefits


  • Demarcation disputes as to “who pays?” are avoided largely.
  • Massive savings in future workforce costs, particularly at management and senior management levels (although initial redundancy costs will be significant).
  • Single forwarded planning policies.
  • Simplicity in managing national expectations and outcomes - the idea that needs and priorities change significantly locally is not real and in any such case social care almost always will follow health.
  • The change can be effected with relatively simple legislation effecting the transfer and the executive action to reallocate budgets.
  • The enablement of a holistic care service. There would be challenges but these seem less than the advantages.
  • Would social care be free at the point of delivery for all? As significant social care is provided to those without substantial means, this may be more philosophical than real. There would be some financial credit where items like accommodation were charged back to users in appropriate cases.
  • Establishing in the public mind that care and health is upon a single continual path of need to be accessed through the same contact points. This is educational but nonetheless a challenge for a prize worth winning - for example, accident and emergency department with social care staff in place would find it easier to diagnose and treat the need away from scarce healthcare resources into a more appropriate setting immediately rather than simply treating symptoms in the short term and encouraging a “revolving door” crisis management position.

If health and social care practitioners and the politicians who lead are serious about “integration”, they should grasp the real challenge and not hover around the edges.

Labour’s idea is good but it requires the courage of real change commitment, just as in the NHS of 1947.

Paul Ridout is a partner of Ridouts LLP