Integrated care north and south of the border

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Proponents of integrated care in England sometimes look to Scotland as an example to be emulated. Yet, while the Scottish NHS has a much simpler structure that ought to facilitate integrated care, the reality is rather different. A report by the Auditor General for Scotland and the Accounts Commission published in 2011 found that community health partnerships, a key statutory vehicle for achieving integrated care, had not delivered on their promise, and recommended a fundamental review to ensure that partnership arrangements for health and social care were effective and efficient.

In response, the Scottish government has recently published proposals for strengthening integration of adult health and social care involving the replacement of community health partnerships by health and social care partnerships. These will be the joint and equal responsibility of health boards and local authorities and will be required to integrate budgets and appoint a senior jointly accountable officer. A partnership agreement between the health board and local authority will establish the services to be delivered and outcomes to be achieved, with the NHS chair and local authority leader expected to form a ‘community of governance’ to oversee the effectiveness of the partnership.

The challenges faced in Scotland in making a reality of partnership working are a timely reminder that structural simplicity and organisational integration do not in themselves ensure the delivery of integrated care. The relevance of this will not be lost on proponents of integrated care in England as the government builds on its commitment to health and social care integration in the care and support White Paper to prepare the framework for integration expected in the autumn.

Just as important is having effective governance arrangements to link NHS organisations and local authorities in place alongside good senior leadership and flexibility in the use of budgets. Health and wellbeing boards could play a key role here, especially if they can engage effectively with clinical commissioning groups (CCGs). The main benefits of integration occur when services are joined up around the needs of patients and users, and CCGs in some areas are already working to make this happen.

The other critical ingredient is clarity on what patients and service users should expect. On this point, the care and support White Paper offered some welcome commitments, including that everyone with a care plan should have a named professional who has an overview of their case and is responsible for answering any questions they or their family might have. The White Paper also stated that there will be a new pledge on care co-ordination for people with complex needs and long-term conditions in the NHS Constitution, which is currently being reviewed by the Future Forum.

Equally important was the commitment in the White Paper to put in place better ways to measure and understand integrated care and to use this information to set a clear, ambitious and measurable goal to drive further improvements in patients’ experience. This commitment follows directly from integrated care proposals put forward by the Fund and the Nuffield Trust in a paper prepared for the Secretary of State and the Future Forum in January. The government’s integration framework needs to build on these developments and encourage innovations in care at scale and pace if the financial and service challenges that lie ahead are to be met.

If the framework does so, and local leaders respond positively, England may yet steal a march on Scotland in the development of integrated care.

This blog was also featured on the British Medical Journal website.


Simon Lawton-Smith

Head of Policy,
Mental Health Foundation
Comment date
26 July 2012
in 1995 the King's Fund published some work on challenges facing mental health services, including "need better interagency work between health, social services, housing, environment, leisure, education". When I use this in induction sessions with new Non Executive Directors of Trusts, I don't tell them it was 1995, I just ask them if the problem is a current and familiar one. They all nod their heads. I then tell them it was the same 17 years ago - and that what they need to do is ensure it's not the same in 17 years' time.

Integrated health and social care does not, as Chris says, necessarily follow on from simple structures. (And nowadays we need to do more in any case than just look at those two branches of mainly public service provision into the wider field of housing, benefits, employment etc, as I hope the Fund's work on chronic Long Term Conditions will demonstrate.) In Northern Ireland health and social care are not noticably more joined up as a result of being the responsibility of a single Department.

But there are some key elements which I think are essential - (a) integrated budgets (b) integrated operational and strategic plans and (c) staff who are not just trained to work in professional silos but are skilled at working across disciplines and in multi-disciplinary partnerships. In other words a workforce that has a basic understanding of a range of health and social care issues and interventions - the classic seeing patients / clients as people, not diagnoses. This is possibly the hardest of the three things to achieve, and could be the reason why many structural changes over the years have been of limited success. Health and Wellbeing Boards are promising on paper, but we await the reality.

Chris mentions care plans. It is well worth looking at Wales' recent Mental Health Measure that makes it obligatory for all users of secondary mental health services to have a care plan that covers eight specific areas of life - finance and money; accommodation; personal care and physical wellbeing; education and training; work and occupation; parenting or caring relationships; social, cultural and spiritual; medical and other forms of treatment. I'm not saying this template would suit all patients, but it's not a bad model to use as a starting point.

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