The Integration Transformation Fund: the foundation of a genuinely integrated system or just another brick in the wall?

'Share it fairly but don't take a slice of my pie', wrote Roger Waters about money, in the track of the same name from Pink Floyd’s classic album 'Dark Side of the Moon' in the 1970s. It's a sentiment that has echoed through various initiatives to bring NHS and local authority social care funding closer together over the past 30 years.

The latest effort is the £3.8 billion Integration Transformation Fund (ITF) (now known as the Better Care Fund) announced in the June spending review, to be spent locally on health and care to drive closer integration and improve outcomes for patients and people with care and support needs. As further details emerge, it's becoming clear that most of it will come from existing NHS budgets – it is not new money. As John Appleby has shown, this is equivalent to an average reduction in allocations to clinical commissioning groups (CCGs) of around £17 million, with potential knock-on consequences for acute and community health services.

So, as the financial pressure on the NHS and local government intensifies, the stakes are high and there are fears that some health systems could be tipped over the edge. The latest guidance is clear that the ITF does not address the financial pressures faced by local authorities and CCGs which remain 'very challenging'. It is a joint fund, not a transfer to social care, so it will be a big ask for CCGs and local authorities to agree how the money will be spent to achieve better outcomes for patients and also satisfy local needs and the national conditions attached to the grant. These include protecting social care services, ensuring seven-day working to support hospital discharge and relieving pressures on urgent and emergency care. Expectations are great but can they be achieved?

The ITF does offer a major opportunity to drive forward integrated care – there is nothing like money to focus the mind – and there are three broad approaches that could guide thinking about how money is used.

The first is adopting an evidence-based approach to what different kinds of service investment (how much, in what kinds of intervention, for how long) will offer commissioners the biggest bang for their buck in both providing a better model of care for users and relieving pressure on the system. We have begun to synthesise our own work and other research about what works in integrated care to assist local discussions about how the grant could be used to achieve maximum impact. These discussions will be testing, as they will involve considering the opportunity costs of a range of choices. In many cases this will require organisations to reduce or disinvest in some activity.

The second approach is about the role of health and wellbeing boards in bringing together local partners. Relationships, especially between CCGs and local authorities, will be key in developing an agreed, costed and deliverable plan – by March 2014 – that offers a win-win for both the NHS and social care. The ramifications for providers could be very significant – which means their engagement in the process will be essential. But our latest health and wellbeing board survey suggests that, as yet, few boards have begun to get a grip on some of the tough strategic challenges facing their local health and care services, with most prioritising public health and health inequalities. The requirement that boards sign off local plans will be a big test of their readiness to offer effective system leadership, rather than rubber-stamping decisions made elsewhere.

The final approach is about using the ITF as a stepping stone to the longer term transformation of services. The requirement that local plans should be part of a five-year strategy for local health and care services from 2015 will be a helpful spur to look beyond the immediate short-term pressures and develop a shared vision of what future local services should look like. The ambition surely should be to plan with 100 per cent of NHS and social care resources in mind, not just the 3 per cent the ITF represents.

With apologies to Pink Floyd, will the ITF be part of the foundations of a genuinely integrated system or just another brick in the wall?

Read the related paper: Health and wellbeing boards: one year on

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Comments

#41131 Dan Allen
Senior Social Work Lecturer
Edge Hill University
Richard your observations are well set out but stop short of recommending what this shared vision should look like. This is mine. We know that professional regulatory concordats in the United Kingdom constantly reiterate the need to increase the focus on integrated health and social care practice. In a continuing effort to shift away from separatism—literally the distinct delivery of health and social care services as detached functions—standards seek to deliver an “integrated agenda,” as it is frequently cited, as an essential component in attaining a more efficient, effective, and augmented public service. The importance of integrated practice is reflected in educational standards which recommend that health and social care education should be underpinned by a curriculum that values effective multiagency collaboration. However, although this philosophy has gained particular impetus within contemporary discourse, including that of the recently announced Integration Transformation Fund, integrated practice and education are not new phenomena. Since 1988, for instance, the focus on a “collaborative movement” has paved the way toward the development of a combined nursing and social work degree, which has been successfully implemented in the UK by a number of educational institutions. Incorporating such policy recommendations, a number of higher-education institutions (HEIs) in the United Kingdom, including Edge Hill University, have responded to the call for more effective interprofessional education with creativity and innovation. Building on an approach that sees nursing and social work being taught within one integrated three-year undergraduate programme, these HEIs have taken into account the fact that nurses and social workers play a crucial role in enabling successful outcomes. Hence, the integration of nursing and social work education into one nationally recognised qualification responds to recommendations that social policy and patient consultation forums so frequently endorse. The HEIs that have taken the step to combine nursing and social work in this way do so with the aim and ambition of creating a new type of worker who is able to deliver both nursing and social work services in the praxis of their professional autonomy. However, ensuring that this objective is realised in practice is complicated. One of the core problems to overcome is the very scale of organizational change that is required to employ one jointly trained nurse and social work practitioner. Indeed, the evidence for the success of integrated nursing and social work education and practice is far from comprehensive. By contrast, other research has linked the difficulties of implementing integrated nursing and social work services, in other words the delivery of nursing and social by one practitioners, with those external forces that serve to determine separatist professional cultures. Although the integrated education of nurses and social workers may well enhance the lives of people who receive services, continued separatism between nursing and social work regulation and remit can seriously undermine the spirit of integrated practice through professional-managerialist conflict. Arguably, as long as professional conflict remains, the full range of opportunities for dual qualified nursing and social work practitioners will be constrained. It is already known that services will almost certainly struggle to achieve integration whilst individual nursing and social work departments experience difficulty in accepting and embracing the fusion of both. Separate professional identities continue to create an “us and them” culture, which can then lead to conflicting opinion. Any potential for conflict could then question the value of this integrated role and its ability to transcend traditional professional boundaries, including how a dual qualified nurse and social worker might engage communities and achieve integrated care. Where adversarial interprofessional relationships continue to exist in the organisation of nursing and social work exist, the same organisations can reach an impasse, reinforced by inflexible and defensive territorial paradigms, which can then bar the pathway to the recommended “integrated agenda” and the need for efficiency in public services. On this basis, I feel that the shared vision should support the implementation of the Integrated Transformation Agenda to engage NHS England, Clinical Commissioning Groups, the Local Government Association and related Authorities so that the opportunities for dual qualified nursing and social work practitioners to work across nursing and social work departments could be set out. Reflecting the education currently being provided, this could focus on the flowing areas: • The full range of learning disability services • Health Visiting • Mental Health services • The development of the ‘Lead Professional’ in family support services • Disabled Children social work • Fostering and adoption services • Community Care • Support for Carers • Hospital at Home Teams - including the discharge planning processes for children with complex needs • School Nursing • Child and Adolescent Mental Health Services • Looked after Children’s Nursing The aim of this, would be to set out a vision that could enable dual qualified nursing and social work practitioners to work within services which might usually be associated with health as required by their roles and responsibilities, but then to be also able to work within services which might usually be associated with social work and social care, again, as required by their roles and responsibilities. Here then the long term view could work to develop a way for these practitioners to work as a nurse and as a social worker within the same role as determined by the opportunities that may be available – in other words as a ‘nurse social worker’.
#41552 Clive Spindley
Technician
QUArk

That is a lot of money and it is easy to spend other peoples money, the key to this is integrating the data and integrating the data does not cost a lot of money. My opinion, for what it is worth, is that integrating the data puts the patient first, if you do not wish to put the patient first step sideways, preferably into a different domain.

#41624 Hugo Minney
Management Consultant
The Social Return Co

As you say, RIchard, money focuses the mind. The best way to get focus on integration is to "integrate" the money, in other words, to combine commissioning of health and social care into one authority. So far I haven't said anything new, but as any health professional will tell you, health and social care services aren't the only factors in a person's life, and can't by themselves, influence the total cost of healthcare required by a given population.
So what else needs to be commissioned by the same single commissioner, with a focus on quality of outcomes and value for money? Housing, education, security, environment. Hmm, sounds a lot like the local authority should take control of health care commissioning, rather than NHS taking control of social care commissioning.
I see two further advantages, apart from drive to balance investment across a whole range of services to achieve best outcomes:
1) local representation. Horror of horrors, local authorities have ELECTED REPRESENTATIVES. I mean, what do the public know about anything? Surely they shouldn't have a say in healthcare commissioning, let alone setting priorities for a local area? NHS has to be planned at national, regional and local level, whereas government only has to be planned at a national, regional and local level...
2) they already have commissioning frameworks with checks and balances for the interdependencies. Many NHS organisations have developed robust commissioning processes, but each has invented its own wheel, and they are not all of them very circular. Whereas local authorities have, of necessity (because they commission so many different services) had to develop a robust framework which each independent commissioning team has to work within.
There's a practical solution. Of course, it won't happen, because it would put too much money into the hands of local government and take it away from the micromanagement of Whitehall.

#42359 kadi Holt
Peadiatric nurse social worker
Edgehill University

Having studied for the past thee years to become qualified as a Nurse Social Worker, I have experienced the need for integrated workers within the health and social care setting.
Service users and patients are continuously having to deal with numerous agencies (especially learning disabilities, mental health, children in need) in order to recive the care and treatmentment need to improve quality of life.
Discrepencies within both fields, due to finance, lack of communication etc have lead to serious case reviews (Laming, Francis Report) which have detailed the need for the 'integration' yet these failures still take place.
I personally feel that employing dualy qualified Nurse Social worker in both settings is a primary need in order to safeguard children and families, cutting out the middle man, enabling professioanls with the knowledge and experiance to be able to identify abuse or neglect in the first instance, which can result in saving lives.

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