Dimensions responds to the health and social care integration white paper.

Fully 30 years ago, governments were talking about integration of health and social care. Back then, it was called partnership working but the aims were the same: the removal of walls between agencies.

The word ‘integration’ appeared in policy papers following the Lansley reforms in around about 2012 and has been in more or less continuous use ever since.

In the past decade, the integration agenda has led to the Better Care Fund, Health and Wellbeing Boards, Integrated Care Pioneers and numerous other initiatives including the Greater Manchester Health and Social Care partnership, with its pooled budgets – which to some extent remains the model underlying the proposals in the White Paper.

Why the history lesson?

Because it is not helpful to see this Integration White Paper in isolation.  Though Sajid Javid and Michael Gove describe it as ‘a start, not an end’, in reality it is a step along a pretty slow and complex journey.

Nevertheless, we welcome the policy’s ambition and scope, putting people and communities at the centre of integration policy. Integration is not an end in itself, but a means of achieving person-centred health and wellbeing outcomes. We are keen to see this ambition matched by funding.

Competition, and procurement

In sweeping away Lansley-era competition rules, the integration white paper may do a lot of good. Our principal concern is around the behaviour of discredited commercial providers of ‘Assessment and Treatment Units.’ Already, we see their names on NHS ‘Provider Collaboratives.’ If competition is a thing of the past, how to ensure the NHS collaborates with the right organisations? Do the reforms even leave the door open to corrupt procurement practices? We don’t know.

Big data

Insofar as anything in this White Paper is disruptive (in the modern, positive sense of that word,) we’d point to shared digital records and the real potential for big data to help place-based leaders deliver better care for more people. (We’d try not to recall the ten-plus billion wasted in past attempts to modernise the NHS IT infrastructure, money that could have been spent on, for instance, better pay for support workers. Keeping things simple.) Yes, if done right big data could be transformative. But it will be costly, and risky.

ICS Health and Care Partnership

Responsible for developing a plan to address the health, public health and social care needs across the ICS footprint, the Partnership is likely to include social care providers. Great! But which? There will be so many social care providers across an ICS footprint – in the high hundreds, potentially – all of which are likely to see commercial value in the influence such a position could offer. As with the procurement point earlier, managing influence and avoiding corrupt practice will be critical.

Transforming care

The white paper states: “A shared outcome for mental health could mean people with mental illness living well in the community.” We welcome the opportunity this presents for joined-up services to provide high quality community support for individuals who are locked up in Assessment and Treatment Units (ATU) because of a shortage of community-based support.  This could have a significant impact on improving the care of individuals with both learning disabilities and mental health needs. Collaboration and joined-up care could annul some of the financial disincentives to discharge too. But we’re not there yet; the proposals are not clear on how ICSs will work in practice, and the role of local government in the new system is poorly defined.

Workforce

The government wants to create an integrated health and social care workforce which can work flexibly across each sector. It plans to introduce an Integrated Skills Passport that would enable staff to move more easily between the NHS, social care and public health. And there’s important rhetoric around parity of esteem between social care and health workers.

However, the proposals do not address the fundamental shortage of people working in all parts of health and social care. Substantial investment in pay is needed to tackle this and to bring social care into parity with health, a point Dimensions has previously made to the Health Select Committee and elsewhere.

The white paper requires the Secretary of State to publish a workforce plan each parliament. We believe this is inadequate, especially given the current workforce position. A responsive workforce plan across both health and social care is required annually.

 

CQC oversight of local authorities

We welcome the recommendation for CQC to oversee LA commissioning and service provision. This is, of course, not a new proposal but it does beg the question about what happens for those local authorities that are on their knees financially – what is the consequence of failure?

Medicalising social care

It has taken decades for the social model of disability to prevail over the medical model. For people’s lives to be seen in their proper social and environmental context, not as problems to be fixed. We are acutely concerned that increased NHS influence over social care could lead to a return to a medical model, with all that that implies. This is no reason to avoid integration but it does require we proceed with caution and balance. After all, people with learning disabilities and autism aren’t patients but individuals who need support to live a full life – at home, not in hospitals.

And finally…

Pooled budgets are not the same as increased budgets.

Pretty much every commentator has highlighted that nothing in the integration white paper eases the current pressure on social care. In particular, the funding and workforce issues remain at crisis point, and unaddressed.