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Feature: A review of the health and social care integration model

David Brindle is a social care commentator and former public services editor of the Guardian. In this feature, he looks at the shortfalls of the government’s integration white paper and what lessons can be learned from local care trusts.

Twenty years ago Mrs Smith was a popular figure on the health and care conference circuit. She wasn’t a real person, but a fictitious 80-year-old with typical needs whose struggles to engage with a range of fragmented services were used to make the case for a new kind of NHS and social care body called a ‘care trust’ that would bring together not only the provision of services, but also their commissioning.

The model was put into practice in a handful of locations across England, most notably Torbay in Devon where Mrs Smith supposedly lived and where the idea flared successfully but all too briefly. Within seven years the local care trust’s commissioning role had been lost and within 10 its structure was dismantled.

The quest continues for what many – but not everyone – see as the holy grail of health and care integration. The present government seems to have a great deal of faith in integration’s potential as a cure-all and has just published a white paper, ‘Joining Up Care for People, Places and Populations’, that in its own words ‘sets out a new approach with citizens and outcomes at its heart instead of endless form-filling, unnavigable processes and a bureaucracy which sees too many people get lost in the system, not receiving the care they need’.

It’s fair to say that the 72-page document has not set the world on fire. In the judgment of the NHS Confederation, the membership body for the healthcare system, it ‘largely reinforces existing policy’ and proposes little that cannot already be done. The social care leaders’ organisation ADASS has described it neutrally as ‘another piece in the reform jigsaw’.

The low-key response is attributable partly to the white paper side-stepping thorny issues such as mandatory pooling of local NHS and social care budgets. Nor does it prescribe a single model for how integration should be enacted at ‘place’ level, which may or may not align with the integrated care system (ICS) commissioning structure taking effect in July, let alone at any neighbourhood or locality level below that. Local leaders would be expected to come up with a tailored plan by spring 2023.

Further uncertainty surrounds the status and powers of the single individual who, under the proposals, would be accountable in each place for achievement of agreed shared outcomes. What levers they would be able to pull, how they would interact with their local ICS and their local health and wellbeing board – which would apparently still exist – and how they would in fact be held to account are issues all unaddressed?

And as with so much else of the government’s social care reform agenda, it is hard to see how progress can be made on integration without first addressing the glaring inequity of pay and conditions between NHS workers and those in social care. A good deal of excitement was generated by an announcement in January by Northumbria Healthcare Trust that it was to deliver social care services and pay workers NHS rates. But the Homecare Association, representing domiciliary care providers, was quick to point out that the trust would need to subsidise by about 100% the £16.36 an hour rate that Northumberland County Council currently pays its care contractors in the community.

While the Northumbria experiment will be closely watched, not least because the trust’s chief executive is the highly regarded Sir James Mackey, previously seconded to head up NHS Improvement, others will hesitate to venture down a similar pathway without assurances on adequate funding for staffing integrated services.

Sceptics of the benefits of integration often say you get nothing by trying to combine two leaky buckets – a term memorably coined eight years ago by former NHS England chief executive Simon (now Lord) Stevens. But the short-lived care trust experiment did offer a glimpse of what might be possible: in Torbay, average daily hospital bed occupancy fell by a third, emergency bed use became the lowest in the region and instances of delayed transfer of care were rendered negligible.

And while care trusts may have had their five minutes of fame, they have left another historical footnote. Last week the government accepted a Labour amendment to the Health and Care Bill, which is legislating for the ICS reforms, allowing elected councillors to sit on the governing integrated care boards. This prompted some head-scratching among governance geeks as to the last time elected local politicians had been able to be a full member of the board of any organisation in England accountable for spending NHS funds.

Most responses to a debate on social media cited area health authorities, which disappeared in 1974, or their district successors which continued until 2000. But a few recalled that the tiny cohort of care trusts had subsequently also appointed councillors, in at least one case to the chair. Their experiences could yet throw up some valuable lessons for those seeking the key to true integration.

Photo by Ketut Subiyanto

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