The Chancellor has drawn up plans to unite the budgets of health and social care in Greater Manchester. The Independent newspaper stated that: ‘A new board of health and council officials would oversee the combined budgets of NHS England, 12 GP-led clinical commissioning groups and the social care provided by 10 local authorities in Greater Manchester.’
This is a brave and welcome move, although some would see it as too little, too late. The aim of this measure is to drive the move towards integration of health and social care, to provide a joined up service to people in need of care.
There are many points of view on this: is it a pre-election headlines grabber, which may not be effective in the long run? How will the free access to services currently in place for NHS patients be reconciled with social care, which is often means tested? Is it a back door to privatisation, or possibly even a cost-cutting measure?
In Scotland too, there are moves to drive the integration of services between health and social care, on an outcomes focused basis. Under the Public Bodies (Joint Working) (Scotland) Act 2014, the Government has released guidance on an outcomes based framework which will be implemented in health and care services which are integrated. An overall statement describes the goals:
‘Health and social care services should focus on the needs of the individual to promote their health and wellbeing, and in particular, to enable people to live healthier lives in their community. Key to this is that people’s experience of health and social care services and their impact is positive; that they are able to shape the care and support that they receive; and that people using services, whether health or social care, can expect a quality service regardless of where they live.’
The Scottish Government envisages integration boards overseeing joint provision of health and social care services in most areas. Services will be based on the already drawn up guidance: ‘Guidance on the Principles for Planning and Delivering Integrated Health and Social Care’. This guidance provides both a strategic and practical reference framework for the planning and delivery of integrated health and social care services.
There is a reassuring emphasis in the outcomes framework on external scrutiny and reporting:
‘Scrutiny bodies; Healthcare Improvement Scotland and Care Inspectorate, when inspecting integrated health and social care services must assess the extent to which the service is contributing to the integration delivery principles and the national health and wellbeing outcomes (sections 54 and 55 of the Act).
Regulations on the performance report require Integration Authorities to report annually on its performance against key measures and indicators in relation to the national health and wellbeing outcomes.’
Of course, getting appropriate care when you need it is a worthwhile goal, and should diminish the national problem of bed-blocking, which poses an urgent and immediate national problem. In Scotland, the Government last month announced a new £100 million funding package to deal with the problem. Over a four week period, an average of 1,216 beds per day were unavailable to incoming patients in hospitals across the country, according to the BBC.
Beds are blocked when a person’s health problems have been treated in hospital, but discharge is sometimes impossible because arranging social care after discharge marches to a different beat. If health and social care are integrated, this should not happen. Post-treatment options can be planned at the same time and by the same people who are arranging the admission into hospital, and the overall experience should be smooth and effective for services and their users.
Or so it would seem. But it is disappointing, or illuminating in a positive sense, to see that bed-blocking can still occur in a policy context where social and health care have long been jointly integrated. In Northern Ireland, this integration is in place. But the Belfast Telegraph announces in its current addition that:
‘Health Minister Edwin Poots identified bed-blocking as a key area to address when he appeared before his committee this week. In the 21 months between April 2012 and last December, healthy patients spent 29,237 days in hospital beds…. The Department of Health target is that 90% of complex discharges take place within 48 hours. … In the worst example, a patient in the Belfast Trust area stayed 635 additional days in hospital – almost two years. ‘
It appears then that integration of health and social care does not improve the increasing crisis that our services face.
Perhaps the Belfast Telegraph hit the nail on the head when it points out that ‘ Northern Ireland’s health service is facing unprecedented demands on its resources … Some 180 hospital beds are also being cut over the next four years.’ Perhaps this points to a solution. In all areas, service providers and in many cases the public are objecting to repeated cuts in the funding and provision of care and health services. But these increasing restrictions occur in the context of increasing expectations of a relatively prosperous and articulate population. The outcome is, inevitably, that the quality of our experience of care, however organised or provided, will suffer, and continue to decline.
Two tactics could be used to weaken this pincer movement of fewer services on the one hand, and mushrooming demand on the other. Firstly, an end to the relentless cuts in funding of services would be wholly welcome by service providers, and would enable more, and more timely social care services. Providers should not have to tender the lowest amount to be sure of getting a contract: instead, costs should be determined by the increasing quality which is expected.
Secondly, demand on acute services could be much reduced in my view by more health promoting services. A preventive approach would inform and support people to take responsibility for their own health: exercise, fresh air, a varied diet and improved social interaction are some of the cheap alternatives to avoid medication, illness and all the increasing burdens which our hospitals deal with at present. An affluent society is not necessarily a healthy one, but we can make it so.
