A holistic approach to care needs is required along with engagement with the wider community to bring about integration within the NHS, writes Paul Burstow
The goal of integration within the NHS, and between social care and healthcare, has been a hot topic for decades. In fact, it even predates the founding of the NHS.
If the Department of Health and Social Care had a resident historian, integration would emerge as the Holy Gail sought by ministers of all political persuasions. More often than not attempts at integration have been at a system level with the focus on structures and reorganisations. At the heart of all these efforts has been the aim to bridge the gap between health and care.
There have been different accountabilities, different goals, different cultures, different funding regimes; one free and the other charged for. A few years ago, I made a visit to Northern Ireland to look at their integrated health and care system. A structural answer to the integration question, NHS and Social Care Trusts, put a wrapper around the two systems but in practice the tensions and differences remained.
From Northern Ireland to England
In England, Sustainability and Transformation Partnerships and the plans for Integrated Care Systems are the latest attempt to square the circle. Again these are seeking structural answers to what are fundamentally issues of culture and behaviour shaped by different mandates, professional perspectives and funding systems.
Jeremy Hunt, in his first major speech on reform of social care, told an audience of social workers that integration had to be personal, about people not structures. This makes sense, especially as there is no appetite or time to legislate anyway.
So what does this mean in practice?
The Social Care Institute for Excellence has been leading a number of initiatives that are about integration around the individual across their health and care needs. We recently launched the logic model for integrated care. Commissioned by the DHSC and a product of co-production, the logic model sets out a theory of change.
It is based around a series of “I statements”, such as: ”I am as involved in discussions and decisions about my care, support and treatment as I want to be”. The model can be used as a tool for thinking about and bringing in a person centred approach to integration. It sums up people’s experiences and the outcomes that matter to them.
SCIE is part of the consortium that is evaluating integrated personal commissioning progress. The consortium’s first report highlights some of the challenges of implementing personal budgets, particularly combining person centred working with integration. The report summed it up like this: “The shift of personalised care and support planning entails having a different kind of conversation with individuals focussed on what matters to them and capturing it in a single personalised plan”.
It is against this backdrop that Jeremy Hunt announced plans to trial integrated assessment and planning across Gloucestershire, Lincolnshire and Nottinghamshire.
The goal for Hunt is a holistic approach to care needs. He explained: “Over the next two years every single person accessing adult social care will be given a joint health and social care assessment and – critically – a joint health and care and support plan, where needed.” I am not sure “given” is the right word; to succeed it requires genuine co-production and a recognition that block contracts are an obstacle to the bespoke solutions people want IPC to deliver.
One of the keys to making progress with integrated assessment and planning is a vibrant community and voluntary sector. In my travels I have seen many great examples of innovation in the delivery of support and care. As SCIE has set out in its work on asset-based places these approaches start with people’s strengths and gifts rather than their weaknesses and deficits.
In Somerset, I met with a flourishing network of micro providers working with local Village Agents. And Derby, Thurrock and Wigan are championing these asset-based approaches, working with the likes of Community Catalysts and Shared Lives. Local Area Co-ordination, Well being Teams, Health Coaches, Social Prescribing; these are just some of the models.
In many cases, these models are complementary. Together, they could form a new eco system offering people who live with frailty or long term health problems (physical and mental) the independence and control they want over their lives. The challenge is scaling these innovations to more people.
The Five Year Forward View says that the NHS can be prone to operating a “factory” model of care and repair, with limited engagement with the wider community, a short sighted approach to partnerships, and underdeveloped advocacy and action on the broader influencers of health and well being. It is time to harness that renewable energy. Without it, Jeremy Hunt’s ambitions for integrated assessment, planning and personal budgets will falter and fail.