Never a better time to make integrated care happen

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The journey towards integrated care is a difficult one, as 40 years of successive attempts to better align health and social care show. Yet, with consensus on the necessity of integrating care, our new report Options for integrated commissioning: beyond Barker argues that there has never been a better time to make the radical changes needed to make it happen.

The imperative to integrate care around the needs of an ageing population with a mixture of conditions and needs that defy service boundaries has never been greater. Yet, responsibility for commissioning has never been more fragmented and is now scattered across nearly 400 separate organisations.

The independent Commission on the Future of Health and Social Care in England, chaired by Kate Barker, pulled no punches in highlighting the deep fault lines between the NHS and social care in terms of funding, entitlements and delivery. The commission’s central recommendation was to move to a single ring-fenced budget for health and social care, with a single local commissioner. Few would agree that our current fractured commissioning arrangements are particularly effective, sustainable or even affordable, but one legacy of the Health and Social Care Act is that the NHS has acquired an understandable allergy to further national reorganisation.

So, are we stuck with the current structures or could we integrate commissioning without plunging organisations into the distracting turmoil of another structural upheaval? From our assessment of the evidence of previous joint commissioning initiatives, engagement with stakeholders and survey evidence, three options for local areas emerge.

The most obvious is to maintain the current policy framework and simply require local authorities and CCGs to find local solutions by working with existing processes such as the Better Care Fund. Some places are making progress in this way but it is much harder where there are poor relationships between local organisations or financial and performance challenges. Overall progress has been glacial – relying on local efforts alone will not deliver the scale, pace and consistency of change that is needed.

Another approach is to require that CCGs and local authorities agree among themselves who should be the single commissioner. This demands very mature local relationships and runs the risk of triggering a battle for control between councils and the NHS when their energies should be focused on collaboration. Past precedents in lead commissioning for learning disability and mental health services do not bode well for this option.

A third option is to revamp health and wellbeing boards and hand them responsibility for implementing the new arrangements. This would require a rebalanced membership, fresh powers and duties and support with commissioning capacity from the CCGs and local authority. This has the advantage of building on current structures but would be a profound step-change that would almost certainly require legislation and a robust capability assessment process to ensure each board is up to the challenge.

All of these options could work in some places but none would work everywhere because of diversity in local geography and circumstances. Rather than prescribe a one-size-fits-all solution, we therefore propose the approach should be agreed locally by CCGs and local authorities on the basis of a clear national policy framework developed by the Department of Health, NHS England and the Local Government Association.

The starting point for this should be to focus on the outcomes of integrated care through a new, single national outcomes framework. Local partners would be expected to agree which option would work best for them in achieving those outcomes and agree a local integration programme to establish a single commissioning function and integrated budget by 2020 (areas than can move more quickly should do so from 2017). The single budget should include all spending on adult social care, community health, primary care, mental health, public health and defined acute services. Local plans should bring together existing Better Care Fund plans so there is one plan, for one place with one set of oversight and support arrangements.

Moving to a single commissioner and single budget for health and social care would not address all the fault lines identified by the Barker commission. But it would be an important and essential first step on the way to the new settlement the commission argued for so persuasively.


Richard Humphries

Comment date
15 June 2015
many thanks for all of these comments, to which I'll respond briefly in turn:
David - yes bold leadership (rather than the defensive organisational self-interest) definitely required & would include political leadership.
George - I value your observations and take the point about the impact of reports. Our next project might help reassure you & I'd welcome a conversation with you.
John - your idea sounds like the old regional/local area health authority structure, back to the future?

Pearl - if I had a tenner for every working party on this subject over the last forty years I wouldn't need to work for a living. Has to be some central direction - but not prescription as to the 'how.

Thank you all again for taking the time and trouble to comment,

Pearl Baker

Carer/independent Mental Health Advocate and Advisor,
Comment date
13 June 2015
It is an almost impossible task for the following reason, LAs are in their own little box, health are in their own little box, neither really know how the other operate. The only way forward is to have a 'working party' including Carers and others agencies involved in both side of the 'coin', then you may make some progress.

Unless their is an independent MONITOR nothing will improve, nobody is accountable for anything, I should know I have worked in the system for thirty years, and where are we today! still trying to understand a system that is getting worse by the day, not helped by the ever ending commands from those trying to cut a 'budget' that cannot deliver a service as it stand at present.

John sturman

retired NHS staff,
Comment date
13 June 2015
Set up regional NHS services one chief executive site managers on hospital sites.Abolish mental health trusts.

George Coxon

Various inc health & social care advocate,
Several NHS and social care directly dependent
Comment date
12 June 2015
I am always a big KF fan & KF promoter. I chaired a MH conference for GPs in London this week & waved enthusiastically both Chris Naylor's now older work on productivity &MH as well as his KF document on LTCs &MH. I also flagged the KF Transforming MH services in London doc from last year plus my published reaction to it. So I'm a KF card carrying member somewhat. But certainly I'm more a real time living & breathing integrationist I own care homes, I lead many fellow energetic care providers exasperated about the continuing division between H&SC. Richard Humphries is a reliable commentator on the imperative for joint budgets structures & combined efforts to KPOOH. Keep people out of hospital. That's where the funding haemorrhage is occurring most urgently. So. These reports? Can we review what impact they are having? Decide on how we get people engaged in making quick real change who are more loyal to the common/ greater good rather than self interest & maintaining chronyistic status quo & self preservation. I'm pretty much one of the little guys small brain etc. but trying to plant seeds and disruptively innovate in my own small way. More of the likes of us need to be brought into the actin planning and risk taking arenas. Thx

David Rosselli

Business Analyst,
Leics CC
Comment date
09 June 2015
An interesting set of proposals! But this will require bold senior leadership at national and local level to become a reality.

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