Surely nobody can seriously suggest that integration is a bad idea.
Why would anyone not want services to be joined up, across institutional, geographical and professional boundaries? Who could possibly dispute that this was a more efficient and cost-effective way of delivering services, and spending public money?
The idea that publicly-funded services should be planned, organised and delivered in an integrated and co-ordinated way is such an obvious proposition that the average citizen might well want to know why this is not already the case, or at the very least a basic objective across the public sector. Why has it even been necessary to introduce new statutory duties and a designated funding stream to achieve this?
The answer, of course, (and let’s be honest: it’s not a great answer) is history. We are where we are because of the ways in which public services have evolved over the last 100 years or more; how successive governments have sought to improve or reform them; how statutory bodies and institutions have evolved, and their duties and responsibilities set down in statute; how scientific knowledge, academic theory and best practice have developed; how economic and social factors have affected priorities; and, of course, how those involved in managing and delivering those services have themselves done their jobs over the years.
We are where we are; but it has to change and there are two major factors driving the integration reform agenda today and making people really challenge fragmentation, silo working and mistrust. The first is economic; austerity is here to
stay. Wherever services and support are fragmented, the result is duplication, gaps, poorer outcomes, increased costs and wasted money and opportunities. We can no longer afford the luxury of such inefficiency.
The second is social: an ageing population. With people living longer, and many living with long-term and often complex conditions, the pressures on services will increase in any event over coming years, which means that the money has to go further, or be spent more effectively simply to maintain current standards.
What is integration?
It is primarily about ensuring that services and support are planned, organised and delivered in a co-ordinated and collaborative way. It is prominent in the context of health and social care; it is fundamental in reforming services within the NHS; but it goes much further in terms of bringing together the ambitions of those delivering a much wider range of services including housing, education, economic regeneration, culture and leisure. Properly it is concerned with any area in which public funds are being expended.
This series of articles
This is the first of a series of 12 monthly articles which will explore the complex subject of integration, considering some of the bigger questions it raises, the challenges and barriers it encounters, and some of the hopes for the future.
There will be two recurrent themes over the course of these articles.
Why aren’t you doing it anyway?
The first will be the irate citizen, wondering why such a fuss is being made about addressing obvious structural or organisational inefficiency. Tax-payers can be justifiably indignant about reforms that should be happening anyway. Fragmentation isn’t just inefficient; it is inexcusable.
But having made that obvious point, we should be constantly alert to the risk of undertaking re-organisation which merely re-arranges furniture without really transforming anything, as well as distracting practitioners, incurring substantial professional fees and disrupting services in the meantime. In every case which seeks to reduce fragmentation and lack of co-ordination, we should be asking: how will these changes make a real difference and embed a new way of working or a new culture through which continuing improvement will thereafter occur as a norm? Tax-paying citizens deserve nothing less. Some disruptive influence may be needed to secure this.
What about me – where am I involved?
The second theme concerns the role of citizens themselves. Integration can and should mean not just that organisations involved in commissioning and delivery should work collaboratively; it should also crucially build in the right role for those for whom the service exists: current and future patients, service-users and carers. Local government and the NHS cannot meet the future challenges on their own; they must accept the need to work collaboratively with those accessing services, those supporting and caring for them, and the voluntary sector too.
In May 2013, the Integrated Care and Support: Our Shared Commitment project jointly endorsed by the Health Minister and the Minister for Care and Support set out a definition of integrated care and support. Co-developed by National Voices through engagement with patients, people who use services and carers, it is as follows: “I can plan my care with people who work together to understand me and my carer(s), allowing me control, and bringing together services to achieve the outcomes important to me.”
This idea is now given statutory force in the Care Act which provides that the starting point for a local authority, in discharging its duty to promote an individual’s well-being, is the assumption that the individual is best-placed to judge their own well-being. If this principle is to be taken seriously, patients, service-users, carers and citizens generally must have a permanent and audible voice within organisational structures and governance (and their redesign), and a clear entitlement to play a full part in designing, delivering and reviewing services.
So integration is something which involves all of us. Not only must barriers be removed between local government and the NHS, between primary and secondary care, between physical and mental health, between health and health-related services such as housing, and between a wide range of other public service providers; but so must the barrier be removed which prevents the citizen from playing a part in influencing, shaping and ultimately controlling the services which they have paid for.
In the next of our monthly articles, we will explore the overarching framework under which integration is being taken forwards: namely the wide range of new statutory duties including the duty to integrate, the NHS Mandate and key policy initiatives. What does this all mean for tax payers and citizens?
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Chris Brophy, Partner and Cliff Mills, Consultant, Capsticks Solicitors LLP