Steve Mathieson is a freelance analyst, journalist and editor, covering IT, government and healthcare, often in combination, writing for publications including The Guardian, I-D Information Daily, editing Society of IT Management's magazine.@samathieson
As the latest King's Fund quarterly study exposes a health service on the brink, SA Mathieson takes a timely look back at the lost promise of "integration", the Torbay experience between 2008 and 2015 and pinpoints Mancunian levels of self-determination as perhaps the best hope we have.
Some NHS organisations are capable of world-class work. The problems start when attempts are made to transfer such practices across the health service. The NHS is, of course, better understood not as a single unit but as a collection of local organisations of varying competence, with many preferring to continue to do things as they currently do rather than make changes.
Health and social care integration, widely seen as a desirable idea, has suffered from the twin difficulties of extending good practice and reluctance to change. The best-know English case study is Torbay, where since 2015 the local NHS trust Torbay and South Devon has provided hospital, community and adult social care. Getting to this state of integration has taken a long time, however, and owes a lot to local circumstances.
Torbay has an elderly population living in a relatively compact urban area. In the early 2000s, Torbay had an underperforming unitary council which had been split off from Devon in 1998 and a strongly-performing NHS acute trust, South Devon Healthcare, which before the introduction of primary care trusts had run the area’s primary and community care. The area had strong motivation, an opportunity and prior experience in joint working.
But it still took several years to develop things. The council and the trust set up an integrated health and social care team in Brixham in 2004, the idea spread to other areas and a merged Torbay Care Trust – which combined Torbay’s primary care trust with Torbay Council’s adult social care – gained approval in 2005. In 2008, the care trust and South Devon Healthcare successfully bid to be a national pilot for vertically integrated care.
Torbay appointed health and social care co-ordinators, who became the main point of contact for referrals. A 2011 assessment by the King’s Fund found that integration led to less use of hospital beds, low rates of emergency hospital admissions for those over 65 and less use of residential and nursing homes in favour of home care. In 2015, the two NHS trusts merged to form Torbay and South Devon.
Why did it take so long? One reason was that Torbay Care Trust was broken up by then health secretary Andrew Lansley’s NHS reorganisation, with primary care transferred to a clinical commissioning group. Central government reorganisations like Lansley’s soak up management time, and their frequent imposition can take some of the blame for the reluctance of NHS bodies and councils to reorganise themselves.
But central government is not always to blame. In 2001, the Labour government created the first model Torbay used to integrate health and social care: the ‘care trust’ where a local authority outsourced social care to an NHS organisation. Despite this political support, only a handful of areas ever set up such trusts, which could focus on mental health and learning disabilities as well as social care for the elderly. Even in Torbay there was some opposition from social workers who felt a “medical model” had been imposed on them.
Integration has developed in a few other areas. The Greater Manchester city region, which took over responsibility for its health and social care budget earlier this year, has a good record: Manchester City Council and the local NHS set up a combined mental health and social care trust in 2002 and in July Salford Royal, one of the country’s most-respected hospital trusts, started providing adult social care services for Salford City Council.
But these areas are exceptions. Integrating health and social care takes a lot of effort and goodwill from strong leaders and organisations, along with political backing and helpful geographic boundaries. There are lots of potential headwinds, including hostile professional groups, managers who are too busy fire-fighting to consider transformational work and a public that often sees change as a smokescreen for cuts to local services.
If other city regions gain control of their health and social care budgets, they may follow Greater Manchester in moving towards greater integration. But in areas which lack strong devolved government or very determined organisations, such integration looks unlikely without government-imposed reorganisation – and that is an answer which tends to cause more problems than it solves.
Torbay and South Devon NHS Foundation Trust http://www.torbayandsouthdevon.nhs.uk/about-us/
Integrating health and social care in Torbay King’s Fund report from 2011 https://www.kingsfund.org.uk/sites/files/kf/integrating-health-social-care-torbay-case-study-kings-fund-march-2011.pdf
In February we wrote a review of the King's Fund Quarterly Monitoring Report #18 titled NHS Finances - the dark at the end of the tunnel http://www.healthcareinnovationmonitor.com/hci/article/nhs-finances-the-dark-at-the-end-of-the-tunnel
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