Features: March 14th, 2014

The split of responsibility for health care between the NHS and local authorities has long been recognised as inefficient and not in the interests of those who use the services. Despite the logic of providing a seamless healthcare system, the process of integration has been slow. This feature describes how the integration process is moving on with the evolution of the Better Care Fund.

On the 30th of January 2014, the chief executives of several local authorities, top transformational professionals, integration experts, and representatives of front-line service providers came together at Local Government House to tackle the tricky issue of realising integrated care ambitions.

Held by the Local Government Association (LGA) and NHS Confederation, in association with Integrating Care, the session was intended to address a specific question: What resources will we need to shift, and how, in order to make better co-ordinated person-centred care an everyday reality?

On the day itself, the thoughtful, frequently impassioned and never dull commentary extended far beyond this. The panel touched on issues from the imminent Better Care Fund (BCF) submissions, to effecting behavioural change, via discussing the right leadership, managerial and communication styles to ease the transition.‘Integration is a question of when and how now, not if.’

The discussion opened with speeches from roundtable chair Sir John Oldham, the LGA’s Geoff Alltimes, and the NHS Confederation’s Michael O’Higgins. Sir John reiterated his long-held belief that ‘specific pathways are a redundant course for the future’ and that we must instead work out how to use integrated pathways to address the rounded needs of service users which he summarised in the sentence: ‘I want you to treat the whole of me, and I want you to treat me as one team.’

Geoff Alltimes acknowledged that what is being attempted in service integration is ‘unprecedented in terms of a collaborative agenda between local government and the NHS, and in the sheer scale of the challenge in terms of the financial circumstances we face.’ And Michael O’Higgins echoed the thoughts of many of the day’s speakers when he said that ‘an awful lot of what we’re talking about has been on the agenda for an awfully long time’, to which Sir John added: ‘Integration is a question of when and how now, not if.’

An honest and inclusive debate

Leicestershire County Council Chief Executive John Sinnott, Cambridgeshire Community Services NHS Trust’s Matthew Winn and Will Tuckley emphasised the importance of including health and care providers in discussions about how we get the best outcomes and provide the best care for the money available. In particular, this debate has focused on hospital care, with little consideration of the role of GPs as providers.

Public Health England’s Strategic Advisor Chris Bull and others made the point that the narrative needs to be widened to an honest debate with our partners and our communities about how we can most effectively improve health but be prepared to take the consequences of the implications for how we currently deliver services.

Martin Smith, Chief Executive, London Borough of Ealing, highlighted the role of the Health and Wellbeing Boards as driving a culture change within local health and care systems on how we reshape care.

Simon Morioka and others stressed the need to do this at scale. There was complete agreement that integration is the only way but we need to accept that savings will not be realised unless integration happens at scale – it must move from the margins to the mainstream.

Start locally, not nationally

One of the key points raised in the session was the difficulty in smoothly reconciling the national, political and local agenda. Michael O’Higgins said clearly that ‘this isn’t about imposing a national structure; it’s about saying “move in this direction – but you decide how you move, at what pace you move, and what exactly is right for you.”’ Nevertheless, a number of the local authority chief execs were concerned that the BCF is driven by the short-term need for ‘quick political wins’ rather than necessarily being right for local areas.

Rob Tinlin of Southend-on-Sea Council felt that too often ‘the decisions are taken too quickly, and some are sprung on us to the detriment of both the local community and the projects themselves. There cannot be a one-size fits all approach; the local politics, not to mention the local media, have to be taken into account.

Margaret Carney of Sefton Council was similarly concerned that the BCF might prove to be a ‘distraction’ and one that could further entrench tribal defensive behaviour: ‘The fact is that the timescale is mad, and we’re in danger of making this a tick-box exercise, when it needs to be a true transformation – this cannot be a sprint.’

Ensuring the BCF is a tool for lasting and positive change
In spite of these concerns, a number of the speakers felt more optimistic about the next steps and about what needs to be done to ensure that the BCF is a tool for lasting and positive change.
Simon Morioka of Integrating Care said in the wake of Margaret Carney’s comments that ‘no one would disagree that the timescales are a bit mad. But they are what they are because they’re being driven by a genuinely pressing need.’

He also said that while the local versus national agenda dichotomy can lead to a bit of a ‘chicken and egg situation’ in terms of effecting change, ‘the BCF has to be the starting point; ultimately a wholesale shift of demand to other [non-hospital] settings is what’s needed to make things better for individuals. The BCF will help drive the change that will improve things in the long term.’‘We have to be more grown-up about getting to where we need to be’

The comments of Will Tuckley, chief executive of Bexley council, were also notable for their positivity. Will spoke about how, after several years of challenges and resistance to hospital change, Bexley has made significant advances of late – but only through recognition of the fact that it’s not health services alone that need to change. ‘We went through every conceivable route and failed,’ he explained ‘before coming to the conclusion that we needed to be talking about what should be there as opposed to what shouldn’t.’ In order for further change and integration to be successful, compromise is necessary – ‘We have to be more grown-up about getting to where we need to be.’

For almost all the council representatives, an important element of this ‘growing up’, on the part of all those involved, is employing greater honesty and openness, particularly when it comes to the financial aspects. There was some concern that the lack of clarity with regard to the BCF being a shift of resources rather than new money has been a hindrance to the integration cause, and has led to more of that defensive tribal behaviour. Indeed a significant number of the commentators spoke of the importance of clear and better managed communications in getting people on board with the integration agenda.

‘It is the public who will decide’

Ultimately, it was agreed by all, the public is powerful, and the communications around coordinated care need to include the public in an honest conversation about the necessity of integration, the benefit for their fellow citizens of not approaching acute services in the first instance, and how to use resources effectively to improve health outcomes.

‘It is the public who will decide,’ said Margaret Carney: ‘They will go to the place they feel comfortable.’
Said Paul Corrigan: ‘We need to focus on how we can work together to break the cycle of older people ending up in A&E – where they don’t want to be and where their outcomes will be worse.’

‘It’s about empowering them, telling them stories, taking them with us as partners,’ said John Wilderspin, Managing Director, NHS Central Southern CSU.

‘Start with the person, and resources will follow’

While not everyone at the table was agreed on every detail of the ‘how’ of service integration, they did all concur on the necessity and benefits of giving people more power in their own care. A distinction was made by Rob Tinlin between referring to the public as patients or service users, rather than citizens. This point was reiterated by many of the attendees: that we need to engage people as citizens, with rights and responsibilities to exercise choices for themselves and their communities responsibly, not as passive recipients of treatment. Michael O’Higgins encapsulated the room’s accord on this point nicely when he said: ‘Start with the person, and resources will follow.’

Debate and disagreement at roundtables like these are important, but to make the citizens the ‘winners’, rather than specific groups in specific services, the discussions ultimately need to find solutions not problems – or as Sir John put it: ‘If one continues to argue and preserve what is, you’ll never get to what might be.’