Devolution is often regarded as a major driving force for integration of services, and it would be easy to assume that the combination of health and social care is central to them all. In fact whilst leading a small number of devo deals, such as those seen in Greater Manchester and London which have integration of health and social care as a key aim, the current deals are more likely to exclude health organisations than include them. Nor is all sorted in the devolved nations, where health and social care are more structurally integrated, but not necessarily culturally working as one. We look at the current arrangements and ask how co-ordination might occur in this mixed economy.
Devolution deals – a quick summary
The devolution deals in place for Greater Manchester and London have collaboration on health and social care as a central theme. A high level review of the remaining devolution agreements shows these to be mainly concerned with devolution of transport, housing, further education and invariably have much less emphasis on health and social care.
Content on health and social care integration
Local Enterprise Partnership
Cornwall Council, the Council of the Isles of Scilly, NHS Kernow and other local partners will work together and with Government, NHS England and other national partners to co-design a business plan to move progressively towards integration of health and social care
Local Government & LEP
Includes a section on health which states a commitment to work together on health and social care integration.
Liverpool City Region
Chair of Liverpool City Region LEP
The second stage of devolution document (March 2016) includes the following section on Health and Social Care
4. As committed to in the devolution deal agreed in November 2015, the Liverpool City Region Combined Authority and NHS partners have been in ongoing dialogue around greater health and social care integration including the prevention agenda. In order to engage fully in this process the clinical commissioning groups across the Liverpool City Region have formed a Committee in Common.
5. The city region, with the full engagement of health partners, will shortly publish an interim report on the case for change across a number of priority health conditions and will now develop a strategy for tackling the issues raised in the report. This will be complemented by the sustainability and transformation planning process, whereby organisations across the locality are working in partnership with others to improve delivery and outcomes.
6. Where the city region believes devolution from the government is required to deliver shared objectives, city region partners will continue to work with the Department of Health, NHS England and Public Health England to develop proposals in this area.
Local Government & LEP
Paves the way for further devolution over time, and for the reform of public services, including health and social care, to be led locally. Separate commission in place looking at health and social care integration.
Sheffield City Region
No mention of health or social care, but plans for further devolution in future.
No apparent mention of health and social care integration.
Local Government and LEP
Emphasis on work to improve mental health and contains some mention of public health. No apparent mention of health and social care integration.
West of England
No apparent mention of health and social care integration.
In summary, the deals mainly focus is on transport, employment and economic development. Only 3 of the 11 agreed devolution deals, Greater Manchester, London and Cornwall, formally include health partners and contain significant emphasis on health and social care integration. The North East and Liverpool both have significant separate work underway in this area, with Liverpool’s progress being captured in the second stage of devolution. The remaining six deals have little or no mention of health and social care integration; the West Midlands has a focus on health, but this is mainly around the equally important issue of mental health rather than integration with social care.
Why so little focus on health and social care integration?
There won’t be a simple generalised explanation for this trend which will be multi-factoral, involving a whole range of historic cultural issues and views that health and social care is high risk, both politically and financially. One possible factor, though, is that working with health is often complex. Whilst health services are consumed and experienced by almost everyone in some shape or form, the governance structures are highly centralised and largely divorced from local accountability. Health organisations and managers have had to respond to the competitive environment favoured by recent governments, and a culture has developed which is more suited to bi-lateral negotiation than joint working. The removal of the regional tiers such as health authorities has left the service divided sharply along functional lines with a clear split between commissioners, accountable to NHS England, and providers who are regulated by NHS Improvement (a merger of the former Trust Development Agency and Monitor from 1 April).
Much of the managerial energy is used up arguing out complex annual finance and performance contracts within a largely inflexible national framework. Add to this a national tariff system which reimburses providers based on volumes, which is very effective as a means to increase activity and reduce waiting lists. Throw financial restraint into the mix and it’s a recipe for disagreement and frustration, resulting in some cases in health economies the parts of which cannot work effectively together, never mind reach out to partners outside of health in a truly collaborative way. Obviously this is not universally so, there are some striking examples of collaborative working and longer term thinking, but I would suggest these are the exception rather than the rule.
The NHS Five Year forward View signalled change in a number of areas including highlighting health and social care integration which, alongside investment in prevention, was cited as being key to resolving the health resourcing conundrum into the future. The first set of sustainability and transformation plans (STPs), due for submission at the end of June, should show some significant moves in the direction of integration, with STP leaders being from local government in a handful of areas (Birmingham, Nottinghamshire and Greater Manchester).
So how can the tanker that is the NHS be turned more quickly towards partnership and joint working? In 2015, CIPFA conducted a series of roundtable events on integration, particularly the Better Care Fund (BCF). In addition to specific worries about the BCF bureaucracy, the discussions drew out four main barriers to joint working which are worth revisiting.
Organisation based thinking
Requires positive attitude and commitment from senior leaders of the organisations to work for the whole population and to be reinforced in wider targets e.g. based on whole population measures
Governance/hosting arrangements unclear
Joint commitment to write in dispute resolution before dispute and monitor what works in practice
Appetites for risk not matched
Organisations need to accept risk in joint working, may need to modify appetite, discuss possible issues in advance through development of a joint risk register
Lack of mutual understanding
Talking / co-location / learning from best practice / Use of resources e.g. CIPFA/HFMA glossary and integration training for finance teams
With the growing NHS ‘to do list’ of balancing the books, achieving waiting times targets, and implementing new models of care with a shrinking pool of specialist staff it would be understandable if it takes good old fashioned central mandation to finally make the difference and force meaningful discussions on integration to take place in all areas. Otherwise we risk leaving behind a set of Cinderella services which are not blessed by the magic wand of devolution. That suggests the Secretary of State has been right to step in by mandating plans for integrated services by 2017, for implementation in 2020.