To what extent, in an increasingly integrated health and social care landscape, can local authorities, the NHS and other partners measure and demonstrate how an action or intervention in one area can lead to efficiencies and better outcomes in another?
This was the focus of discussion by a high-level panel representing local government, healthcare and academia as well as research experts, a reflection of the importance of data collection and management in this context.
Paul Carey-Kent, policy manager for health, social care and welfare reform, Cipfa
Tim Gilling, deputy executive director and head of programmes, health and social care, Centre for Public Scrutiny
Nick Golding, editor, LGC (chair)
Sanjay Mackintosh, head of strategic commissioning, Haringey LBC
Michelle McGuire, research director, Databuild Research & Solutions
Richard Preece, medical director and managing director of care delivery, Allied Healthcare
Chris Skedgel, deputy director, health economics consulting, Norwich Medical School, University of East Anglia
LGC editor Nick Golding, who chaired the session, said integration is often seen as a catch-all solution to the increasing stretched financial position of both the NHS and local government but the reality is generally more complex.
“Integration is a great means of co-ordinating services and ensuring a better-rounded quality of care for individual recipients but there isn’t that much discussion on a national level about how to measure the outcomes we are seeing from this integrated system. Indeed, what actually constitutes an outcome?” he asked.
Part of the problem was that even the term ‘health outcome’ was weighted with complexity, said Richard Preece, medical director and managing director of care delivery at Allied Healthcare.
“When we talk about an outcome it’s not just about what that outcome is. It’s also how we might get to it, and I see outcomes for the people we look after in terms of a journey,” Dr Preece said. “We’d like them to get to a certain kind of destination, and we can define what that destination is with them. But some journeys we go on are smooth and swift, and others are disrupted. If we’re not careful we end up with a rather polarised debate; we focus on a very ‘hard’ outcome without thinking what that might mean.”
Within healthcare, the methodology of assessing outcomes from interventions, and therefore their value, was relatively clear-cut, said Chris Skedgel, deputy director of health economics consulting at Norwich Medical School at the University of East Anglia. Unfortunately, the same could not be said about social care.
“There isn’t a corresponding process or methodology around social care, often because the things we’re trying to achieve in social care are so diverse that it’s hard to assign one particular measure,” he said.
“There’s some danger in that we end up focusing on what’s easy to measure rather than what’s important to measure.”
“We are trying to work with our colleagues a lot more, and the challenge is planning much better upfront. This is in itself difficult, particularly within acute and healthcare services, where it is their purpose to treat things that go wrong and move on,” said Sanjay Mackintosh, head of strategic commissioning at Haringey LBC.
“That feeds out into that discussion about ‘what is the journey?’. How you measure it, what the pathways are, how we get people into the right settings and how to measure those points. How do you discharge people in a timely way into a social care setting? How do you provide the right settings to not reinstitutionalise them in a different place but reable them? I would agree the journey isn’t mapped properly, and therefore it isn’t measured either.”
“We’re often measuring people who are in the system, so they’re already receiving health or social care,” said Tim Gilling, deputy executive director and head of programmes, health and social care at the Centre for Public Scrutiny. “What we lack is a whole-system understanding of the risks prevalent in communities that direct people more towards becoming ill or needing social care.
“There may be very creative and innovative ways in communities to keep people independent, healthy and increase their wellbeing. But I’m not sure we’ve got that system-wide understanding yet.”
This need for ‘wholesystem thinking’ was important, said Paul Carey-Kent, policy manager for health, social care and welfare reform at the Chartered Institute of Public Finance & Accountancy. It was also important to make a distinction between what he termed “allocative efficiency”, or ensuring money was being spent in the right place, and “technical efficiency”, or whether that spending represented value for money.
“Maybe a good sign of a successful integrated system will be that you’ll get better allocative efficiency decisions, which will mean you’re spending more on prevention for long-term benefit and investing more in the community and less in acute settings,” he said.
There needed to be a shared understanding of inputs and activities, immediate and long-term outcomes, said Michelle McGuire, research director at Databuild Research and Solutions. “Then it’s about having a clear sense of the causal path between them and being confident that the immediate or short-term outcomes are going to lead to longer-term outcomes. The longer-term outcomes are harder to measure; and in a sense you want to be able to measure things earlier on in the journey to know you are on the right track.”
Given these issues raised, should the question therefore be less about how to integrate and more why, Mr Golding asked.
“I’d even challenge whether we are integrating,” said Dr Preece. “Integration used to mean when you brought things together and maybe made them one. Actually that’s not really what we’ve talked about. What we’ve talked about is getting people around the same table and trying to get them broadly on the same page, and that’s not really integration, it’s co-operation.”
When you looked at the respective histories of local government and the NHS, it very quickly became clear that, while there were superficial similarities, in reality both were very different beasts, suggested Mr Mackintosh.
“If we think of the statutory footing of the NHS in relation to government legislation; it’s changed the NHS continually for goodness knows how long, since it pretty much started. The government can say, ‘we will scrap primary care trusts, we will get rid of strategic health authorities, we will create clinical commissioning groups’ and so on.
“But in local government, on the other side of the integration fence, it’s on a completely different statutory footing; it’s fully elected, we have politicians. You have two very different systems and governance operating and trying to become as one.”
The lack of quantitative data for specific interventions within social care was another significant challenge highlighted by the panel.
Mr Skedgel said: “Many of the evaluations we get into on the social care side start from the presumption that, if we deliver the same service in a more appropriate location, we’ll get better outcomes. But if it’s the care itself that is inappropriate, not necessarily the location of it, you’re not going to change outcomes just by delivering ineffective care in a different location.”
But it was also true it was often much harder to measure or capture the effectiveness of interventions within social care than in the medical arena.
“If you’re treating hypertension you can measure quite accurately the change in somebody’s blood pressure. But if you’re trying to improve resilience or independence in the community those are much more nebulous concepts. So it’s not just a matter of saying, ‘let’s just start measuring things’,” he said.
Ms McGuire also raised the question of whether there was an issue of cultural or intellectual prejudice, an expectation of what data or evidence ‘ought’ to be.
“I feel like the health area is blessed and spoilt by the ability to measure hard data, which means there’s a lot of value placed on quantitative data; when you’re talking about data you’re instinctively talking about hard numbers,” she said. “You have to wonder whether there’s a value judgement against qualitative data, because you instinctively feel in the social care space there would be the ability to measure qualitative data quite easily, in terms of your carers who go and visit every day. They will be able to tell you day in, day out what their view of it is. But I wonder whether there’s a value judgement that’s not as good as the hard numbers that are in the health space and therefore that’s not measured or thought of in the same way.”
“Ultimately you have to put the two together,” said Mr Mackintosh. “So, better, hard metrics on things like demand, changes in need, through social care assessments and what does that look like, against, at a more individual level, carer contact or surveys, to give you some sort of structure for what qualitative good outcomes look like.”
As the debate drew to a close, Mr Golding asked the panel for any final reflections, especially around the question of “how do we measure outcomes?” and whether this was even now a relevant question to ask.
“It feels to me like there isn’t one answer, there are different ways of doing it,” said Mr Mackintosh. “What we have done in Haringey is use a combination of hard metrics and more qualitative outcomes in order to say, ‘here’s the objective we’re trying to achieve at a population level and we have to measure it through a combination’. So a hard metric might be something like the number of safeguarding alerts coming in, against which you ask a person whether they’re feeling happy today. You put the two together and that’s the best that we have at the moment.”
“They don’t call economics ‘the dismal science’ for nothing,” said Mr Skedgel. “There’s all that challenge around outcomes, which I totally agree with. But I think there’s a second layer of complication in that a lot of what we’re trying to accomplish in social care is specifically tailored to a particular population. To the extent that we are even able to generate hard outcomes, it’s not a guaranteed thing that what worked in Manchester, say, is going to be directly translatable to Norwich or London.”
“If you take the view integration is something we’re going to pursue as a good thing in principle, then we probably want to try and measure ‘have we achieved integration?’ – working jointly, IT systems, jointly planning, budgets and so on,” said Mr Carey-Kent. “Then maybe measure how you are looking at the balance between prevention, long-term, short-term, those sorts of issues. And then have we got some hard measures of what integration does in practice? We’re not at the stage necessarily of specifying what those are but the very fact that you can locally discuss and set some measures is probably what you should be saying and doing.”
One answer might be to look at the joint strategic needs assessments created by health and wellbeing boards, said Mr Gilling, as these can begin to capture how things are working across a whole area or system. From there it could be a question of drawing up a three-, five- or 10-year plan articulating what those needs should be, how the pattern of provision needs to change, and the steps that need to be taken as a result.
“That’s about leadership and vision and aspiration. But that has to include the user voice; that has to include some notion of dialogue with communities,” he said.
“The question is, where does that leadership come from?” said Ms McGuire. “It feels that in different areas it has bubbled up in different ways. But that’s the difficulty, what are the structures? Because in the way things are disaggregating there’s nothing naturally that will take that role and push that forward.”
“Unless the stakeholders are clear about each other’s expectations, then really we can only be as strong as the weakest link in the chain,” said Dr Preece. “It’s really about clarity of expectations; if everybody goes into an integration project very clear what everybody else is wanting to get out of it, there is a pretty reasonable chance that that might happen. “But if it’s not really clear, then very quickly someone’s going to become pretty disaffected. So it’s about clarity of expectations of different stakeholders. It will get there, though.”
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