Integration or Bust? What are the choices for health and social care?
26 November, 2013

Today (Thursday 21st November) a discussion event with a difference was hosted by NLGN and PA Consulting Group. Dubbed “local government fight club”, the event was made up of three debates covering the most contentious questions in local government health and care provision: Integration, a national care service and achieving sustainability.

The health and social care crisis facing local government is well documented; an ageing population will outstrip the supply of health and care services that the sector can afford.
By focusing on the three strategic shifts facing health and social care, NLGN and PA have brought together key figures from local government, the health service and the private sector to tease out the key areas that are impeding progress.

Delegates first debated issues around health and social care integration – and whether this was either right or inevitable.

In favour of integration was Steven Pleasant, Chief Executive, Tameside City Council who argued:

“It is patently unaffordable to continue the way we are. Pressure will come down on adult social care as it is harder to cut children’s services and we have no control over demand led benefits. We also spend our money on the wrong things – on failure not intervention.”

“A GP in Tameside told me “I don’t even know who my health visitors are”. Others have said the same thing elsewhere. This is the result of a fragmented service. We’ve been obsessed with economies of scale and have forgotten economies of scope.”

“Evidentially we know what’s important, we know we should move to models of predict and prevent, but we don’t because we organise ourselves across silos and fragmented systems. We have siloed not holistic workforce plans. These are in the interest of providers not users.”

“Integration means the money is invested in community services – accessible and holistic primary care. Help where and when it is needed. It is a no-brainer!”

Against was Paul Simic, CEO, Lancashire Care Association who countered:

“We have been talking about integration for 30 – 40 years and it hasn’t happened. Nobody argues against cooperation and collaboration. But integration means lots of different things to different people. Integration is a distraction. It channels our energy to secondary functions. It over-emphasises organisational processes over people and relationships and encourages change overload.

“There is not a lot of evidence that there are wide savings to me made from integration. There seems to be a lot of over-claiming, because we feel something must be done and our preference is for something hard and simple not soft and complex.”

“There is clear evidence that structural integration does not deliver effective service improvement. The emphasis should be on service integration rather than on organisational integration. Moreover, the focus should be on specific aspects of individual partnerships which deliver particular outcomes for identified groups.”

Delegates next debated the concept of a national care service, taking primary responsibility for
care away from local authorities and putting it in the hands of central government, leaving local government to focus on being leaders of places?

Speaking in favour was Jim Graham, Chief Executive, Warwickshire County Council who argued that:

“The current conceptual framework around local government and the NHS is an unhelpful place to be. When local government was tasked with reducing the cost of care, we did so very effectively. So successfully, that providers were complaining that they couldn’t cover the cost of decent care.”

“Local government is as much a part of the problem as the NHS. Integration is a sideshow, but the striving to integrate leads you to focus on the end users and their needs – not service delivery needs. We develop many wonderful services, but staff become very proprietorial.

“We need a two tier workforce. Local Government is the commissioner of the marketplace and will continue to deal with the complex care needs. But 80 percent of the traffic will go to a market driven service. Morph Health and wellbeing boards into commissioning services. Core commissioning responsibilities will be to champion the most vulnerable within a marketised system.”

“This is about self-run care. A National Consumer Council – independent of local and national government – with local systems would oversee the development of individualised self-run care programmes.
“The Secretary of State for local government post should be abolished and replaced with a Secretary of State for Local Public Services. The current set up is not the voice of local government (or of health), they are the consumers’ champions. This would make more sense with a national consumers’ council for them to negotiate with.

“The local government market is too crowded as it stands. We need fewer models. We cannot sustain the number of local authorities and public bodies that we have. We should have one simplified body that puts the consumer at the heart of the service”

But he was countered by Martin Samuels, Commissioner for Care, Staffordshire County Council who believed:

“Staffordshire is very typical of Middle England but is also a place of ferocious complexity. Is a national solution going to work in a place as complicated as Staffordshire? If not, how would the rest of typical and untypical England fare?

“We recognise we need to change the fundamental relationship of users to public services. People are going to have to do far more for themselves, as the state simply won’t have the capacity to cope with high levels of intervention.”

“We are also very aware of the interconnection between many of our public services at every level. It is an inextricably combined and connected system. To take out Adult care would be to make this even more complicated. We also know that we have local complexities and how to implement solutions that are responsive to each of our different areas. We commission solutions that work for particular areas.”

“We are splitting our adult social care in a number of different areas to deliver the different solutions needed, while retaining the strategic understanding of what is needed for Staffordshire.”

“From a commissioning perspective we are aware that adult social care is just one part of the wide range of services we manage. To move these decisions to a national body would take away the knowledge of impact on other local services.”

The NHS dos not provide a particularly good model of provision of services with user control and user choice, which is essential to the shift in public attitudes needed.”

The day ended with an afternoon session on sustainability. For social care to be sustainable, where should the cost burden of care fall? What innovative funding and investment models might be developed to ensure the sustainability of the system? This debate was facilitated by Steve Carefull, adult social care specialist at PA Consulting Group, who said:

“These ideas of integration are really big and complicated things, and it will be the Secretary of State or Prime Minister who will make the final decisions. But there are some great things that can be done by local government now to improve sustainability.”

At the moment, delegates agreed that 2020 is as far in advance as they are able to look, but most planning is done on two year cycles, as that is the most certainty they can have.

But they are trying to roll back the public sector, empower individuals and communities and change attitudes and expectations, which is a lifetime’s change.

One key factor in sustainability is the better sharing of data and understanding of how this can be used across services. This has the capacity to reduce lots of duplication, but it can be really hard to get all those involved to share and use joint systems.

Building social capacity is another key area for local government with the potential to produce great savings, but these will not be seen immediately, and the challenge is to prove the value of this work in the immediate term.

There is a recognition that local government can’t do everything, but that there are some things they should be picking up. Perhaps it is about them managing their market to pick up where services are not able to be provided or negated through behaviour change.

Of the day, Director of NLGN Simon Parker said:

“By challenging some fundamental assumptions around health and social care, we can enable local government to consider the radical solutions that are required if we are to have a system that is sustainable and fit for purpose.”