Health and social care – an unlikely merger

The government wants greater integration between health and social care, apparently, but little thought has been given as to how this will be achieved, says Bob Hudson

Guardian readers woke up on Thursday to a remarkable headline – David Cameron orders merging of health and social care. Health secretary Andrew Lansley has been told, it was said, to “drive through the changes”. Could over 60 years of frustrating fragmentation be coming to an end so swiftly and simply? The occasion of the story is a new report from the establishment think tanks, the King’s Fund and Nuffield Trust, to the NHS Future Forum which, in turn, is expected to shape policy at the Department of Health. But what does the report actually say, and what is really going on?

Contrary to the impression given by the Guardian headline, there is no proposal for the merging of health and social care – indeed the very first paragraph claims that integration “can be delivered without further legislative change or structural upheaval”. Although there is little new in the report, it does contain some interesting proposals which, if taken seriously, could change the policy landscape. In particular it calls for:

• The Department of Health and NHS Commissioning Board “to set a clear, ambitious and measurable goal that is linked to patients’, users’ and carers’ experience of integrated care and that must be delivered by a defined date”.
• Action to be taken to develop a single outcomes framework to promote joint accountability for delivering services that are joined up.
• Payment incentives and new “local currencies” to encourage integrated care.

This is all reasonable stuff, albeit that the report is very light on how any of this will be achieved. However, there are other aspects that are less convincing. First, the entire report is written from an NHS perspective, with little apparent understanding or awareness of the world of adult social care. There is little or no mention of the huge cuts being imposed upon local government, of the tightening of eligibility criteria, or of the potential undermining of democratic legitimacy as decision-taking drifts away from local councils. The much-vaunted Health and Wellbeing Boards do not even merit a mention and, all in all, social care is perceived as a handmaiden to the NHS. To this extent the report is politically naive.

Secondly, although apparently eschewing the need for structural change, little evidence is offered to suggest that forty years of mainstream policy failure can be reversed by voluntary partnering. The report praises achievements in Torbay but fails to note that this has been achieved on the back of organisational restructuring using the Care Trust model. It is surely optimistic to imagine that integration will come about through joint commissioning, least of all – as the report argues – by scaling up general practice “to provide the platform for integrated care”. The only form of team working GPs understand is one in which their own practice problems take priority and they call the shots, a model with little appeal to social workers or community nurses. The reality is that unless and until budgets are under one roof (and here the bun fight will really begin) integrated care will be elusive.

Finally, there is the crucial matter of the way in which the health bill (there is precious little social care in it) prioritises competition over collaboration, and whether the two can comfortably co-exist. The establishment think tanks understandably believe they can, despite acknowledging that choice and competition policy “appears at times to run contrary to the desire for integrated care”. Monitor is urged to take “a proportionate approach that encourages both”, but it is admitted that “it remains unclear in practice how the rules of competition and integration will be interpreted”.

This may well be the point where the entire mission falters. The reality is that competition and collaboration do not comfortably co-exist – at best we can have more of one and less of the other. Indeed this “trade-off” judgement will be precisely the role of Monitor, but who imagines that Monitor will do anything other than prioritise competition? Two-thirds of the health bill is taken up with the rules for competition and Monitor’s new role in enforcing a market in healthcare. Monitor will be remote, unaccountable and with no evident understanding of the purpose and value of integrated care – although the King’s Fund and Nuffield Trust have been commissioned (again) to support it in this task.

The reality on the ground right now is that far from assuming a larger role, integrated arrangements are being actively dismantled. The implosion of primary care trusts has destroyed the established networks developed with some progressive local authorities; some pathfinder CCGs are demanding the repatriation of “their” community nurses from integrated teams; councils are withdrawing social workers from integrated mental health teams; and disputes between councils and PCT “clusters” about responsibility for funding continuing healthcare are escalating. The integration clock has indeed started to tick – but it may be going backwards.

Bob Hudson is a professor in the school of applied social sciences at the University of Durham.