How can we ensure benefits are taken into account across the whole system?


The Local Government Chronical, in association with Allied Healthcare, held a roundtable debate to look at the future of health and social care integration. It brought together a high-level panel representing local government, healthcare and academia. The discussion tackled issues of principle around how to measure performance as well as the narrower question of whether, in an increasingly integrated health and social care landscape, local authorities, the NHS and other partners can measure and demonstrate how an action or intervention in one area can lead to efficiencies and better outcomes in another.

The ‘whole system thinking’ which this would require has been a focus of CIPFA’s integration round tables and its publication Let’s Get Together: Integrating Health and Social Care (PDF 849 KB).  Where health and social care systems continue to evaluate their outcomes separately only by reference to their own responsibilities, there is a danger they may take actions which fail to maximise whole system outcomes with potential benefits to patients being lost.

Social Care outcomes were felt to be harder to measure, making them less likely to be built into Health evaluations. Within healthcare, the methodology of assessing outcomes from interventions, and therefore their value, was relatively clear-cut, said Chris Skedgel, Deputy Director of Health Economics consulting at Norwich Medical School at the University of East Anglia. Unfortunately, the same could not be said about social care.

"There isn’t a corresponding process or methodology around social care, often because the things we’re trying to achieve in social care are so diverse that it’s hard to assign one particular measure. There’s some danger in that we end up focusing on what’s easy to measure rather than what’s important to measure,” he warned. “If you’re treating hypertension you can measure quite accurately the change in somebody’s blood pressure. But if you’re trying to improve resilience or independence in the community those are much more nebulous concepts. So it’s not just a matter of saying, ‘let’s just start measuring things’," he said.

"We’re often measuring people who are in the system, so they’re already receiving health or social care. What we lack is a whole-system understanding of the risks prevalent in communities that direct people more towards becoming ill or needing social care,” said Tim Gilling, Deputy Executive Director and Head of Programmes, Health and Social Care at the Centre for Public Scrutiny.

"There may be very creative and innovative ways in communities to keep people independent, healthy and increase their wellbeing. But I’m not sure we’ve got that system-wide understanding yet," he said.

"This need for ‘whole-system thinking’ was important," said Paul Carey-Kent, Policy Manager for Health, Social Care and Welfare Reform at CIPFA. "It was also important to make a distinction between what he termed 'allocative efficiency', or ensuring money was being spent in the right place, and 'technical efficiency', or whether that spending achieved best value for money wherever it was spent. Maybe a good sign of a successful integrated system will be that you’ll get better allocative efficiency decisions, which will mean you’re spending more on prevention for long-term benefit and investing more in the community and less in acute settings."

"I feel like the health area is blessed and spoilt by the ability to measure hard data, which means that there’s a lot of value placed on quantitative data; when you’re talking about data you’re instinctively talking about hard numbers," said Michelle McGuire, research director, Databuild Research & Solutions. "You have to wonder whether there’s a value judgement against qualitative data, because you instinctively feel in the social care space there would be the ability to measure qualitative data quite easily, in terms of your carers who go and visit every day. They will be able to tell you day in, day out what their view of it is. But I wonder whether there’s a value judgement that’s not as good as the hard numbers that are in the health space and therefore that’s not measured or thought of in the same way," she added.

"Ultimately you have to put the two together,” said Sanjay Mackintosh, head of strategic commissioning, Haringey LBC. “So, better, hard metrics on things like demand, changes in need, through social care assessments and what does that look like, against, at a more individual level, carer contact or surveys, to give you some sort of structure for what qualitative good outcomes look like."

"If you take the view integration is something we’re going to pursue as a good thing in principle, then we probably want to try and measure ‘have we achieved integration?’ – working jointly, IT systems, jointly planning, budgets and so on," said Mr Carey-Kent. "Then maybe measure how you are looking at the balance between prevention, long-term, short-term, those sorts of issues. And then have we got some hard measures of what integration does in practice? We’re not at the stage necessarily of specifying what those are but the very fact that you can locally discuss and set some measures is probably what you should be saying and doing."

"One answer might be to look at the joint strategic needs assessments created by health and wellbeing boards," said Mr Gilling, as these can begin to capture how things are working across a whole area or system. From there it could be a question of drawing up a three-, five- or ten-year plan articulating what those needs need to be, how the pattern of provision needs to change, and the steps that need to be taken as a result. "That’s about leadership and vision and aspiration. But that has to include the user voice; that has to include some notion of dialogue with communities," he said.

It’s unsurprising that the group concluded that this is a difficult area. If, for example, we want to invest optimally in public health, we need means of assessing and taking account of the cost consequences across the whole system. Perhaps that would reduce the likelihood of the government on the one hand accepting the importance of public health investment through its endorsement of the Five Year Forward View, and yet on the other hand deciding to cut spending on it.


Tim Gilling, deputy executive director and head of programmes, health and social care, Centre for Public Scrutiny

Nick Golding, editor, LGC (chair)

Sanjay Mackintosh, head of strategic commissioning, Haringey LBC

Michelle McGuire, research director, Databuild Research & Solutions

Dr Richard Preece, medical director and managing director of care delivery, Allied Healthcare

Chris Skedgel, deputy director, health economics consulting, Norwich Medical School, University of East Anglia

Paul Carey-Kent, policy manager for health, social care and welfare reform, CIPFA