Time to take stock on the challenge of integrating health and social care

Three months ago, just as everyone enjoyed the uncharacteristic heatwave, the National Audit Office (NAO) published a little-noticed Report called the health and social care interface. Sir Amyas Morse, the Auditor General, admits that some might find it ‘discouraging’. It certainly turns up the heat on Ministers and Managers to do more if the commitment to integrate health and social care by 2020 in England is remotely achievable. We focus on the implications for public consultations.

But first, the overall picture. Despite a succession of policy initiatives stretching back to 1999, progress continues to be slow. The NAO identifies several factors that make this so difficult. The obvious one is money. It quotes Simon Stevens (Chief Executive of NHS England) at the Select Committee: – “putting two leaky funding buckets together does not make a watertight health and care service …” It acknowledges the misalignment of strategies between the two sectors. But mostly it focuses on the well-known organisational and cultural differences that make working together so challenging. Fusing together democratically-accountable councils with the strongly autocratic top-down NHS system is bound to create tension.

All this makes some recent achievements quite remarkable. There is indeed a lot of impressive progress. But nowhere is the challenge better illustrated than in the public engagement arena, and the processes of consultation that are required before significant changes are made to cherished public services. Professional engagement staff from local authorities or from the NHS are equally challenged with the task of managing dialogue with stakeholders. Here are six critical issues they have to address:

1. Identifying the consultor
Generally speaking, people recognise their own councils – they also probably relate to the locally visible parts of the NHS. But their relationship with these organisations are different, and the new Integrated care systems, whatever they are called will take time to establish themselves in communities’ perceptions, let along their affections. Even the most skilful communications teams have to tread carefully in the kind of image they create.
2. Observing statutory provisions
The NHS has more demanding and explicit statutory obligations which, among other things, requires it to involve public and patients in the development as well as the consideration of proposals for change. Whilst local authorities have to fulfil many legitimate expectations for consultation, there are few requirements for them to engage people in options development – and only few Councillors become involved. When planning changes that straddle health and social care, you need to observe the more demanding rules.
3. Aligning strategies
Care pathways for both social care and health have been evolving for years. The available options often reflect the local infrastructure – especially around major hospitals and the range and quality of providers clustered around them. It is often overlooked that much of local social care is provided by the private sector or by voluntary bodies, and the way in which these have been managed over the years matters. Reconciling these with more nationally-driven strategies for the NHS can be tough. A classic disconnect is where council policies to reduce pay levels in social care has created workforce shortages that frustrate attempts to reduce the cost burden on hospitals. Even cleverly-worded consultations cannot disguise such misalignments.
4. Educating communities
Most people do not understand social care. Ipsos MORI says that 63% of the population thinks, wrongly that it is provided by the NHS; 49% think, wrongly that, like health, it is free at the point of need. With such widespread misconceptions, proposals to modify the way people receive care will be hard to explain and often hard to justify for change will be seen by many to be threatening, especially if accompanied by gloomy predictions about a lack of money.
5. Focusing the debate
Complex reconfigurations have centred around high-profile centralisation of Accident and Emergency units or Maternity/Paediatric services. Both are dominated by debates about access times. The other hotspot is bed closures which the public perceive to be counter-intuitive at a time of more older people with more complex long-term conditions. Consultations have struggled to focus the debate on the positive benefits of more integrated working because the detailed homework and the (NHS best-practice) participation-based options development has not as frequently been undertaken for community services.
6. Maintaining credibility
The Care Quality Commission (CQC) has started to look at how local areas are coping with these integrated pathways. The NAO has used the CQCs findings to sound alarm bells about local leadership. In their earliest days, STPs struggled with credibility because many councils saw them as NHS creations unresponsive to democratic accountability. In fact, the relevant statutory mechanisms created by the 2012 Act were Health and Wellbeing Boards, and these have in many cases proved disappointing and unable to take the lead role that was originally envisaged. Without the formal status of those bodies, make-it-up-as-you-go-along non-statutory devices such as STPs have been vulnerable to attack from any disgruntled Councillor, Member of Parliament, newspaper or broadcaster whenever they dislike an emerging proposal.

CONCLUSION

We are in the middle of a challenging experiment – requiring these different public bodies to work together to consult the public on tough choices. Anything that goes wrong – as it did in Stoke on Trent – or any apparent reluctance to consult in the first place – as it did in Corby, and the process can be expensively stalled. And community confidence can be set back years. These exercises must be done to the letter of the law and to best practice standards. The Institute has, of course, developed to meet precisely these scenarios, and over the coming weeks, will offer its members and supporters some practical tools and training to equip them to tackle this task with confidence.