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Richard Humphries: NAO report shows integration takes years

Richard Humphries
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The government’s plans to integrate health and social care by 2020 are not working.

That is the stark conclusion of the National Audit Office’s latest assessment. It found no compelling evidence that the current array of initiatives – the integration pioneer sites, the better care fund and NHS England’s new models of care – has saved money, reduced hospital activity or achieved better outcomes for people. Governance and oversight has been poor and expectations of the rate of local progress has been unrealistic.

We have been here before. Health minister Enoch Powell urged councils and the NHS to collaborate in shaping new plans for local health and welfare services. Sixty-six years later the involvement of local government in its 21st century reincarnation, sustainability and transformation plans, is patchy. The last five decades have been peppered with top-down initiatives that had limited impact and were quickly abandoned or forgotten.

So how can we learn from history instead of repeating it? A key lesson is avoiding the mistake of expecting too much, too soon. The King’s Fund’s extensive work on integration in the UK and abroad is unequivocal in its conclusions: the best examples took years to develop and owe more to local vision and leadership rather than the latest top-down national initiative. Successive governments have overestimated what can be achieved in the short term and underestimate what can be achieved in the longer term. Then there are fundamental national fault lines which all governments have found too difficult politically to address, notably that health care is universal and free at the point of use whereas social care is heavily means tested and rationed. There are also big national barriers around misaligned financial incentives, workforce and information governance.

An important message of hope is that local progress is possible; for example, many places have reduced admissions of older people to long-term care and used reablement to avoid hospital readmissions. The NAO is surely right to call for the government, NHS England and NHS Improvement to establish a much more coherent national framework that supports not hinders local ambition.

Richard Humphries, assistant director, policy, the King’s Fund

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