The barriers to integration

24 February 2012

Local leaders must be empowered to stick to their guns and lead change, says Jo Webber, deputy policy director of the NHS Confederation

While debate rages over the Health and Social Care Bill, a lot of store has been placed in the ability of integrated services to provide better care for patients and better value for money in the longer term.

As a result, integration has been written into one of the most contentious parts of the Bill concerning the economic regulator Monitor's duties.

The fact is, however, that promoting integration has been government policy for decades. Despite this, successful integration has been the exception rather than the rule and continues to promise much while actually delivering little on the ground.

There are impressive exceptions. For example, a recent report by the NHS Confederation's Mental Health Network looked at the integration of mental health and acute services by Birmingham and Solihull Mental Health NHS Foundation Trust and Birmingham City Hospital. The rapid assessment interface and discharge (RAID) service offered a comprehensive range of mental health services regardless of patient age, presenting complaint, time of presentation or severity, for all adults using City Hospital.

An evaluation of the service showed it offered better care and better outcomes for patients. Further analysis by the London School of Economics revealed that the service was likely to save, at a conservative estimate, £3.4m a year and savings could be as high as £9m.

The really big prize, however, is to integrate health and social care. The typical NHS patient is now someone who is older, is likely to have more than one illness and, increasingly, has both health and social care needs. The two systems are going to rely on each other more and more as our population gets older. They have to work together properly.

There are examples of successfully integrated health and social care systems. Torbay is most often cited but there are others such as Blackburn and Darwen and Cumbria County Council. Again, however, these are exceptions.

To learn more about why integrated care has not flourished across the country it is necessary to look at these exceptional cases and what the people who run these systems have to say.

This is exactly what the NHS Confederation did, with the Association of Directors of Adult Social Services, in order to feed views into the follow-up work on social care by the government's Future Forum.

When you get down to it, the main barriers to successfully integrating health and social care can be summarised in three words – money, power and risk.

Money, because payments, budgets and funding streams need to be aligned properly. Funding flows differently through different organisations and it is extremely difficult to integrate payment systems between them. This is particularly difficult across health and social care because some funding comes from the NHS, some from the local authority and some from individuals.

Power, because it is absolutely vital to work out how decisions are made across organisations and who is accountable and responsible for them. People also have to be able to cede power to others. It is worth noting that many of the successful cases have risen from situations where one of the "sides" - either the NHS or local government - has been in crisis and required radical action initiated by a more stable and powerful partner.

Risk, because leaders recognise how big the challenges are. The risks over money and power can be considerable, local and internal opposition can become overwhelming and government agencies may intervene.

These are pretty fundamental barriers as they concern not just the structures people work within but also the way they work.

Structural changes, recommended by the Health Select Committee recently, such as pooling budgets, selecting a lead commissioner and working towards a shared set of goals that local people can hold you accountable to could all help address these issues.

What has to happen at the same time is the development of strong relationships across organisations and changes to the way people work. There is little point having various structures aligned if the organisations working within them are not talking to each other, working together for patients on the ground, sharing information and clear on how they are going to work to achieve shared outcomes.

It is this kind of organisational culture change that often proves hardest to get right. It is has to start from the bottom up so local people, patients and staff all know that their local services are working together towards a common goal, based on offering the best possible care for patients using the funds available.

It is really important therefore that local leaders are empowered to lead this change: to take risks, to stick to their guns and to improve care for patients.