Why can’t health and social care services get it together?

Integration is the newest NHS buzz word, and it’s not hard to see why.

Integration would remove duplication, increase efficiency be more effective and be more customer focused.  We would no longer employ social workers and community nurses to do the same job with the same people asking the same questions much to the irritation of patients or service users. No longer would time and good will be wasted on arguing over who pays what on individual care packages. No more arguments about who is responsible for delayed hospital discharges. No more demarcation disputes between occupational therapist, social workers and community nurses.

It seems that integration would solve most of the problems. Yet Health Service Journal’s editorial last week reveals slow progress and considerable confusion about what is meant by “integration”. 

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. What those in social services often fail to recognise that a lot of energy is being expended trying to get coordination and cooperation between acute hospitals and GP practices, acute hospitals and the ambulance service, GP practices and mental health trusts. No wonder there is little time and energy left for the small poor cousin that is social services.

Integration is not new everywhere though: in some places they have had integrated teams of social workers and community psychiatric nurses for years. Integrated teams working with people with learning disabilities have been created in many places and integrated teams working with older people are in place in some localities. The challenges of this bringing together are illustrated by an examination of these so called integrated teams. Most of the mental health teams were integrated only in that they shared the same building. They were different teams, with different managers, their own separate budgets and totally different computer systems which couldn’t talk to each other even if there had been an agreement to share confidential information let alone have a one file per client/ patient. Much of the work over the last ten years has been to try and address these issues at a local level.

Progress has been patchy but the power to operate a pooled budget for learning disabilities was a big step forward. Of course it did raise issues of trust, transparency and different accounting systems. It also exposed a difference in culture where social service were accountable to local people through local councilors and NHS service were not. Not so much a problem when there is a growth budget and an opportunity to fund new services but a problem when budgets are cut.

Much progress around integration of health and social care has been put back by reorganisations and mergers of primary care trust because the key individuals the chief executive, Directors and head of finance changed. Deals done on the strength of personal relationships started to unravel under budget pressure. The introduction of commissioning into the NHS and further budgets cuts in local government and health will further undermine attempts at integration.

How long will the flu jab be a free jab?

I went to see the film Contagion at the weekend all about a global outbreak of a deadly virus. The film struck an uneasy chord as I had received my annual flu jab that morning.

Like a lot of other people I get it free on the NHS because I am in a high risk group. This seems a good example of a health service rather than a sick service that is keeping people well rather than only treating them when they are ill.

I first started having flu jabs when I worked for social services in a children’s home. The manager was keen to reduce the risk of lots of staff going off sick with the resulting implication for covering shifts to say nothing of the cost in overtime! As staff we agreed to this not so much for flu prevention but because we knew that as live in staff if you did go off sick and had received the flu jab you would be sympathetically treated and the opposite was also true.

As a senior manager in social services I encouraged staff working in residential homes or as home helps to have the flu jab. At the time we were happy to pay for it because we recognised we were supporting large numbers of very vulnerable people who would not be able to survive at home without their three or four visits a day to provide meals, help dress and visit the toilet, get into and out of bed and supervise the taking of medication.

These days residential care and home help services have largely been passed to the private sector. Instead of the local authority social service department providing a home help service it now has contracts with dozens of small and medium size business to provide home help. The same is true of residential care: my local authority now directly runs only a handful of homes but has contacts with over 500 in the private sector. Do these employers pay for their staff to have a flue jab?

As a senior manager I considered making it part of our contacts but the homes rightly pointed out they couldn’t make staff have the jabs. The thing is with the private sector they are only going to do something if it helps the bottom line. In other words will they save more money in reduced sickness than it costs to provide the jabs? Which of course depends on whether they pay sick pay and overtime. Staff on casual contacts or self employed don’t get sick pay and some companies don’t pay overtime.

We know what the consequences are for vulnerable and dependant people if their home help doesn’t come but what are the consequences for the provider who admits visits are being missed due to staff sickness? Do they lose the contract? What if there is no one else able or willing to take over the contract? What happens in the mean time to the frail elderly people or those suffering from dementia who missed their visit today and will miss out again tomorrow?

Which brings me back to free flu jabs and the NHS promoting health rather than just dealing with sickness. If we continue to model healthcare on the private sector as we have for social care then it won’t be long before I am paying for my flu jab.