Social care providers and integrated care systems: opportunities and challenges

For people unfamiliar with adult social care it sometimes comes as a shock to realise the sector’s size and diversity. It employs around 1.5m people in around 17,700 organisations, most of which are in the private sector but with a decent number of voluntary sector organisations as well.

The sector’s reach is wide – there are, for example, more beds in care homes than there are in acute hospitals and the sector employs nearly 800,000 frontline care workers who work not just in residential care but in community and home-based settings. It’s a sector, then, that has huge importance and potential within the wider health and care landscape.

An opportunity but also a challenge for newly created integrated care systems (ICSs) is how to best engage with adult social care to deliver on ambitions to support the health, wellbeing and independence of their populations, addressing workforce challenges and designing integrated, person-centred services. It was for this reason that NHS England asked The King’s Fund to explore with adult social care providers their hopes and expectations for integrated care systems, their current level of engagement in ICSs and what could be done to improve involvement.

We spoke to nearly 40 providers from across adult social care, some individually and some as part of focus groups. We also spoke to the bodies representing social care providers, such as Care England, the Homecare Association and the National Care Forum. In total around 14 hours of interviews and focus groups took place during April 2022.

What we heard demonstrated both the potential of the social care sector and the challenges that will need to be overcome to fully involve it in integrated care systems.

We heard that adult social care providers are clear they bring values, knowledge and skills that are essential to the vision of ICSs. Providers spoke about their passion for the principles of person-centred care and the importance of their reach into communities and homes, often – thinking of home care in particular – into people’s living rooms. They also talked about the knowledge and data that this experience provided, and its potential for service planning and prevention.

Providers saw real potential in ICSs to improve the outcomes for individuals and their families, and to shift the health and care system towards a more person-centred approach. They also saw opportunities for efficiency and collaboration on issues of joint concern, such as staffing.

'Providers saw real potential in ICSs to improve the outcomes for individuals and their families, and to shift the health and care system towards a more person-centred approach.'

However, there were real barriers to their involvement and providers were not shy in telling us about them. They spoke with passion and often frustration about the cultural differences between health and care, and what they saw as a lack of trust between the two sides. They spoke about basic misunderstandings of what the ASC provider sector is and does, and a lack of trust in the expertise of their staff. All this led, they said, to a paternalistic, transactional relationship in which ASC providers did not feel valued or appreciated. This needed to be overcome for providers to be fully engaged in ICSs, they said.

Providers recognised that the scale, capacity and particularly the diversity of the sector was a further barrier to involvement. This was partly a question of available time for smaller organisations but also, for larger ASC providers, to engage with multiple ICSs. There was also a clear recognition among providers that the scale and diversity of the sector meant it struggled to represent itself, and that it might therefore need to adapt to engage with ICSs.

We felt that many of these issues had their roots in the deep and complex cultural and historical divisions between health and care, including the division between a ‘free’ NHS and a means-tested social care system, an NHS that is largely staffed and delivered by public sector workers and a social care system in which most providers are in the independent sector, and a clinically focused NHS and a social care system that increasingly focuses on individuals’ wider wellbeing.

'We felt that many of these issues had their roots in the deep and complex cultural and historical divisions between health and care...'

But we didn’t feel the challenges were insurmountable. We suggested three immediate actions. In the short term, there is a need to improve communication and engagement by ICSs with adult social care providers, most obviously as integrated care strategies are developed. More generally, there is a need to improve the basic understanding between the health and care sectors, to tackle some of the divisions that currently exist. Finally, there is a need to develop structural options for adult social care providers to be involved in ICSs.

With integrated care partnerships due to develop their integrated care strategies over the coming months there is an opportunity for partners from across health and social care to come together and identify the work they want to do together in areas like prevention, workforce, digital transformation and new models of care. DHSC has new guidance on how integrated care partnerships and adult social care providers are expected to work together.

No one should imagine that the full involvement of adult social care providers in ICSs will be achieved simply and quickly but it is essential and a ‘litmus test’ of ICS’s ambitions: a marker of the extent to which ICSs genuinely set out to transform local health and care systems.