Is the time now right to integrate health and social care?

This year marks the 20th anniversary of the fall of the Berlin Wall, but as the former Health Minister Lord Warner noted at a debate at The King's Fund this morning, with a few exceptions the Berlin Wall between health and social care still stands.

Progress is being made in areas such as Torbay and Knowsley and they've also embarked on a radical route in Herefordshire. Chris Bull, chief executive of both the PCT and the county council, pointed to the potential for integration but cautioned against seeing it as an end in itself – joining up commissioning is about driving new means of delivery which reflect the needs of those using services rather than those who provide them. Meanwhile the senior civil servant responsible for social care in England, David Behan, claimed there was a need for a better understanding of why integration worked in some places but not in others.

Much of this could have been said 20 years ago. The big question now is whether we have reached a tipping point – a moment when factors will come together to bring about a step change. According to Lord Warner it needs political will at the centre and he was unsure whether that will exists.

Certainly the Green Paper on social care funding has moved this issue higher up the political agenda than it has been for many years. Politicians have been competing for attention with various schemes, some rather better than others. But, as was made clear by a number of this morning's speakers, any reform of funding must go hand in hand with service reform – people will not be willing to pay more for the same services.

There are a number of unanswered questions. First, how far will central government be willing or able to move to a system of national assessments and entitlements in social care?

Second, is it possible to devise a system of incentives – for both health and social care – which encourages the development of more community-based services, discourages unnecessary hospital admissions and fosters joint pathways and teams?

And third, where does the current, rather muddled picture of specialist commissioning, PCT commissioning, practice-based commissioning, social care commissioning and micro-commissioning (by individual patients and other users holding their own budgets) all fit together?

Behind this though looms the impending squeeze on health funding and the ongoing cuts in social care budgets. There is a danger that it could encourage a bunker mentality – we must all strive to make it a stimulus for reform.