How can we deal with financial pressures in health and social care?

The financial pressures facing health and social care can be approached in one of two ways. Organisations can adopt a fortress mentality and seek to protect themselves in the current harsh climate, regardless of the impact on others. Alternatively, they can reach out to partner organisations and work towards a whole-system solution, even if this means sacrificing their own interests for the greater good.

Our recent conference on building an integrated system of care drew on experience in England and other countries to identify four key building blocks of a whole-system solution. First, it is essential to align financial incentives to make it easier for organisations to work together. Current payment systems in the NHS and social care fail to do this, and in a forthcoming paper we shall be exploring how these systems need to be reformed to support the development of integrated care.

Innovations such as bundled payments and year-of-care funding hold promise, but more radical options such as allocating a capitated budget to a lead provider or a provider network merit serious consideration. The experience of high-performing integrated systems such as Kaiser Permanente, which were discussed at the conference, illustrates the advantage of capitated budgets. The flexibility offered by these budgets enables providers to deliver the new models of care we have argued are needed in the future in our Transforming the delivery of health and social care paper.

Second, whole-system solutions require a different style of leadership in public services. The familiar ‘pace-setting’ style that predominates among top NHS leaders must be complemented by a willingness to facilitate change by working with others to deliver improvements in care. This in turn depends on the ability of leaders in different organisations to establish the trusting relationships on which successful partnership working hinges. The Fund will be playing its part in this process through its leadership programmes and support in the field to leaders involved in the development of integrated care.

Third, whole system solutions must keep the needs of populations and service users at the forefront of their efforts. By asking how they can work together to improve outcomes for Mrs Smith, to invoke the fictional user who has helped Torbay deliver impressive results by integrating health and social care, public sector agencies can transcend organisational rivalries and find common cause in the desire to use their combined resources for the benefit of the people they serve. And by ensuring users are fully engaged in the development of integrated care, these agencies can avoid the ever-present danger of providers assuming they know what users want.

Last, but not least, whole-system solutions must be based on sound governance arrangements with absolute clarity around decision rights and accountabilities. Senior leaders of the organisations involved need to provide overall direction supported by joint executive teams and dedicated programme management support. In the absence of these characteristics there is every chance that organisations will go their own way and the fortress mentality will prevail.

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#1888 Harry Longman
Chief Executive
Patient Access

Can I suggest a fifth key building block? We have to build with things that work. These will be found by looking for what is already working. They are unlikely to come out of what used to be known as smoke filled rooms (rooms with bottled water on the table?)

#2042 Helen Spillards

The NHS needs to take advantage of services that can be funded by 3rd parties to help take some of the pressures of it, whilst supporting it at the same time.

#2087 Mike Smith
Vice Chair
Patients Association

The demography is the driver behind integrated care - especially for the elderly who take up more than 2/3rds of acute beds and 1/4 of them are not getting the care they need because they're stuck in an acute bed after their acute phase with nowhere suitable to be passed onto, either their own home with professionals coming in or to a properly organized care bed. Also, the exchequer would then get the care it needs. Acute bed £2300 per week, care bed £700 per week - 3 for the price of one. It's not rocket salad as the tomato said to the cucumber - or summat like that! Why are we dragging our feet?

#2092 Alex Fox
Shared Lives Plus

The most important kind of intergration in meeting public health and long term conditions goals is the integration between formal and informal, paid and unpaid caring. Health and care services, and in fact all services, are only one part of the picture. We must integrate the contributions of services around the contributions of citizens, families and communities to deliver a sustainable NHS.

#2095 Roger Avon
Retired accountant
Avonova Ltd

I think one of the biggest problems which is being proliferated by the Government's changes is the lack of critical management mass. Let's start streamlining at management level first before we start at the frontline. We could afford a lot more frontline staff, equipment, drugs etc if we amalgamate small/medium trusts, abolish GP management groups (nothing worse than doing the wrong thing really well, so beware!). We need to protect point of delivery services, free services, pursue vigorously integrated care etc. Only wish I was not retired and could influence policy as it is just so sad seeing all the blunders made, not learning from them and the new blunders in the pipeline.

#2140 Andrew Bamji
Consultant rheumatologist
Chelsfield Park Hospital

When I started in the NHS there was an integrated system (excluding social services) which was destroyed by the purchaser-provider split. Pity we must waste time and money re-inventing it. However I despair of success; however one fiddles with the system, however good the managers may be (and the track record is not encouraging) it is not possible to rescue an organisation that is totally bankrupt without making very hard, if not impossible decisions on what the NHS will stop doing. If Kaiser Permanente is so good why has it not spread itself across all America (and why have there been no pilots in the UK)?

#2143 Bernd Sass
Strategic Partnership Manager
Disability Rights Uk

All very valuable hints. Yet, the link to everything is building on the lived experience of people with support needs themselves. We have the engagement models ready in our pilot programme 'user-driven commissioning'. Starting by pooling their personal budgets (to achieve greater economies of scale) disabled and older people use their insights gained to push for de-commissioning (from block to spot) and finally deliver peer support as an integrated element of new cross-sector care and support pathways. This on the ground initiative will bring about whole systems improvement, integration and productivity gains - rather than more of the high level stuff.

We just need more commissioners to open access to budget information and enable financial modelling and co-produce solutions with disabled and older people and their organisations. All starts and ends with lived experience.

#2191 Jeremy Taylor
Chief Executive
National Voices

Nice one, Chris. Your third building block will be stronger if the focus on the end user is bolstered by a concerted drive to involve patients (and their carers) in decisions about their care; if there is a concerted drive to give people more support to live as well as possible with their health conditions; and if key metrics of patient involvement and experience are given more prominence.

#3201 cameronf
Global KAP

I think there needds to be a reality check. I mean everyone wants to live forever now and no one wants anything but the bst when most people should be sent home or have the bubble wrap taken off them. healthcare for everyone and more so we all dont get sick and can not get bed ridden.

preventive healthcare has to be the next way forward for government, rather than reactive. egg exercise for all or incentives to do so etc...

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