11th November 2016
Disrupting our thinking on integration
It is not new to say that closer working between health and social care services is essential to achieve better outcomes for people. It may be somewhat more surprising to note that talk about integration goes back to at least Enoch Powell. In 1961 as health minister, Powell called on “local health and welfare authorities, through the bodies
which represent them, to take a hand in mapping the joint future of the hospital and the local authority services.”
Setting out his vision for integrated community-based services (and announcing a massive wave of hospital closures) he argued that admission to hospital was no longer to be the only way of accessing services: “Hospital building is not like pyramid building, the erection of memorials to endure to a remote posterity. We have to get the idea into our heads that a hospital is a shell, a framework, however complex, to contain certain processes, and when the processes change or are superseded, then the shell must most probably be scrapped and the framework dismantled.”
55 years later, have we really got this idea into our heads? It seems not.
Research commissioned by the LGA and carried out by Newton shows that about one in four people admitted to hospital do not need to be there and could be looked after elsewhere if the care system was designed to facilitate more effective decision making and if better use was made of services available to treat people in the community.
Helping more people to be independent and looked after at home or in the community could save the English health and care system more than £1 billion because admissions to hospital and residential care cost so much more than looking after people in their own homes. Services such as re-ablement not only give people back their liberty and quality of life, they free up resource which can be better used elsewhere.
So why has such a simple idea – that working together provides better services to people and allows resources to go further – been so difficult to put in place more comprehensively?
One reason is that organisationally we focus a little too much on managing external complexity (another health reorganisation, I hear you say?) and a little too little on service delivery. In the context of social care, this means that our organisational leadership capacity can be too focused on the complex, constantly changing and frustrating governance, planning and partnership arrangements (of which STPs are just the latest example in England) and too little on the care pathway. As part of the LGA’s research, health and care practitioners examined thousands of
anonymised case notes in five parts of England. The analysis found that 26% of hospital admissions could have been avoided if opportunities to intervene had been available or not missed.
Furthermore, the research found that 45% of pathway decisions could be better. The current system doesn’t support practitioners to make consistent, outcome-based decisions, often leading to over-provision of care, reducing the service user’s independence while costing more. It was found that robust, multi-disciplinary reviews at key decision points have a significant impact on consistency and quality of decision-making provided they are supported by the right ways of working.
In simple terms, improving decision-making along key stages of the care pathway would improve care, maximize independence and reduce costs.
Powell thought that the difficulties he would face in implementing integrated community care would be the resistance of well-meaning, dedicated people worried by change. That is no doubt a factor all organisations encounter. But it is perhaps not the biggest challenge we face in the current context.
The research found unambiguously that stronger decision making and micro-commissioning presents the prime opportunity to do better things better in health and social care. The challenge to local authority chief executives and senior managers is to ask whether they are deploying the right balance of their leadership capacity between the eternal, external complexities of governance and structures and sorting out the straightforward co-ordination of different agencies’ services.
By Mike Bennett, Director, Public Intelligence and Senior Adviser to Newton