Are expectations for integrating health and social care unrealistic?
Despite successive governments recognising the potential benefits of supporting older people to stay well, avoid injury and get back on their feet after a hospital admission, it has proved difficult to achieve change in practice.
That does not mean that there has been no progress. There are re-ablement and falls prevention services available in most local areas, and numerous examples of innovative projects being delivered through the third sector. However, the much called-for shift to a more preventive model is yet to become a reality.
Integration is seen as one means to facilitate this change and is being promoted as such within current policy. This is on the basis that people are falling through the patchwork of available preventive provisions, and better linkage of these services will lead to people being identified and supported earlier. These concerns reflect the common experience of the people who work in services and those who stand to benefit from improvements.
Research also highlights that we are not always joined up in how we promote, deliver or indeed commission preventive services. However, the case for integration being the magic ingredient for such systemic ailments is less established. National programmes such as the Partnerships for Older People Projects (Popps) have demonstrated that better joint working between public and third sectors, and across housing, health and social care, can improve outcomes for individuals and decrease their use of public resources.
However, they also highlight that some forms of integration work better than others, that their impact does not always increase when scaled up, and that there can be considerable variation in outcomes between what appears on paper to be similar service models. Such programmes also demonstrate the difficulty in fully understanding the benefits (or otherwise) of preventive interventions, with evaluation teams coming to different conclusions.
Integration may still be a potential or indeed necessary component for the preventive cure that we are seeking. However, we need to be realistic about the complexity of fragmentation that has to be addressed and the considerable barriers around these that will need to be overcome.
Intervening successfully will require us (or specifically health and wellbing boards) to be clear about the local gaps that should be the priority for action. If strengthening is required, this should be done through improving communication and co-ordination of current structures, rather than developing new organisations or major disruptions. And the integration must be specifically tailored to address the fragmentation in question. If not, there is a danger that the time and energy spent achieving integration will have distracted us from more impactful initiatives.
We need to be clear and realistic about the desired outcomes, and avoid the historic tendency for new partnerships to have great and arguably unrealistic aspirations about what can be achieved on a short timescale. Being clear on outcomes will also help with putting in place relevant processes to understand how the improvements are working in practice, with the new value case modelling toolkit launched by the Local Government Association proving a framework to be followed.
Correctly diagnosing, treating and monitoring the local fragmentation is only the start. Research and history reveal that many promising integrated care initiatives have been disrupted or sidelined by competing policy interests, power dynamics between different bodies, and pressure to deliver immediate savings in response to unfavourable financial environments.
Such cracks are already in play within the current climate of restructuring and uncertainty. Integration is likely to be part of the cure for our crisis-based system, but like most tonics will only work if it is administered properly, with sensitivity to potential side-effects and as part of an overall package.
Robin Miller is a senior fellow at the Health Services Management Centre at the University of Birmingham.
