How can health and social care be encouraged to integrate?
By Debbie Andalo
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| Older people account for 75% of NHS activity, so it is vital that healthcare reforms are tailored to their needs. Photograph: Gareth Byrne/Alamy |
Older people are the biggest users of the NHS, accounting for 75% of activity. They occupy 60% of hospital beds, according to figures from the charity Age UK, and it is estimated that their health and social careneeds alone account for most of the £70bn spent each year on patients with long-term conditions.
With the number of people aged over 85 expected to double in the next 25 years, it is crucial that the NHS of the future has the capacity to cope with the increased demands that this group of patients will bring. But do the planned changes for England outlined in the government's health and social care reforms offer older people the prospect of improved services in the new-look NHS? And will the reforms produce a more integrated health and social care landscape, which encourages more holistic and seamless care for these elderly and vulnerable patients?
These were some of the issues at the heart of a roundtable debate hosted by the Guardian and sponsored by the independent care home provider Barchester Healthcare, which looks after more than 10,000 older people across England, Scotland and Wales. The event was held under the Chatham House rule, which allows comments to be reported without attribution to encourage free debate.
Integration of health and social care is critical if the needs of older people are to be met in the future, the roundtable was told, but in 80% of cases it does not happen. "The reality of integration seems so far away from our real experience that it seems almost crazy to talk about it."
It was said by one participant that bringing social care and health together worked well when there were strong local relationships and leadership, while imposing integration on providers was destined to fail. "I don't think integration works from the top down," they added. The contribution which housing can make to the health and social care agenda was also now beginning to be recognised, which was seen as an important step forward. "People talk about the role of housing in a way that hasn't been talked of before," the roundtable heard.
Innovation
There is emerging evidence that the new clinical commissioning groups (CCG) starting to be set up as part of the government's health reforms, can promote integration, trigger innovation and improve services for older people. Under the reforms local CCGs, in most cases led by GPs, will control 60% of the NHS budget.
Significantly, the changes take the purchasing power away from health service managers and puts it into the hands of clinicians. Referring to the early success of CCGs, a participant told the roundtable: "We are seeing it [integration] working and have achieved a great deal in five months. We have been working on integrated care and have a complete multi-disciplinary approach to managing high-risk elderly patients. There is real engagement between GPs and consultants."
But the roundtable believed the transition to CCGs and health and social care integration was a "huge challenge". One participant wanted to see more national support and guidance on the way forward. That was, however, unlikely because more "support from the centre" was at odds with the government's "localism agenda", the roundtable heard.
The creation of CCGs has, for the first time, forced clinicians to scrutinise local health services and seek improvements, said one participant. "Primary care trusts have always struggled to engage clinicians to look at services and how they can be improved. The [CCG] board has managed to achieve something which was always a failure in the past – we have now got real clinical engagement in improving services for the elderly."
The reforms, according to one contributor, created a climate of innovation in integrated care. "There is a groundswell of innovation happening. It's remarkable, I haven't seen this in five years of doing integrated care." The challenge, however, was how to go about rolling out innovation. "There is a lot of evidence about what good practice looks like. The challenge is why can't we scale up? That is always the big challenge around innovation."
The future success of CCGs will be down to how motivated GPs are in getting involved. Professional integrity, which can be reflected in how family doctors take their responsibility for care home cover, is also key. A contributor, referring to care home GP services said: "GPs range from excellent to [those who behave like] used car dealers. That is quite scary." Care homes frequently had to pay GPs for services, the roundtable was told, and on occasion they have demanded personal cheques rather than a payment being made out to the practice. "It's disgraceful," a participant said. There was a danger that the same culture could develop in CCGs, the roundtable was warned. "There is some very destructive behaviour around. Some CCGs are driven by power or whether they can make money out of it – they don't think about the patients, they are thinking about the opportunities. I think we need to be guarded about that."
It was estimated at the roundtable that 25% of GPs who take on commissioning responsibility do so not because they are "visionaries", but because they are looking for new business opportunities, a contributor said. GPs, as a profession, are not traditionally attracted to commissioning roles.
A participant said: "What motivates them is developing services in their practices with their partners, and influencing the way that health care is delivered locally for the common good." The new CCG system had to recognise that, if it wanted to encourage GPs to take a lead in creating innovative local services for the elderly. "If we are going to free them (GPs) up more it's about not micro-managing the process," the participant said.
There were also other risks attached to the government's health and social care reforms, which were highlighted by the roundtable. The desire for all trusts to take on foundation status, which would mean they would be free from central government control, created a danger that they would become "monolithic" providers of services, squeezing out other providers; the system of payment by results was also a disincentive for them to move activity out into the community to different providers. An NHS which has to find £20bn of efficiency savings by 2015 also means that CCGs could be driven to make savings, commissioning "pockets of care which doesn't work for the care of the elderly", a contributor warned. Another participant was concerned about how CCGs would cope once the vital managerial support from primary care trusts (PCTs) disappears when they are abolished in a year's time: "At the moment we are working well because we still have the managerial support of the PCT. We are going to fall down if we don't have multi-professional support. We have real concerns about next year."
Another key worry was that the NHS reforms are not happening in isolation, they are among a raft of changes happening across public services which could have a far-reaching impact on older people. A participant said: "Whole systems are changing. Not just health but local authorities are facing cuts and there is the Welfare Reform Act. If you [drop] that all on somebody's life that is a very worrying place to be. Having public services which you depend on collapsing and changing all at the same time will place an enormous pressure on health and social care services – not least because of the worry and the stress."
It is hoped some support will come from a new network of health and wellbeing boards, which are being established at local council level as part of the reforms and will be required to work closely with CCGs. The boards have a broad public health remit and will bring together health and social care to influence commissioning decisions.
The roundtable acknowledged that the boards had a "huge amount of potential" but there was concern that they might become another town hall sub-committee or talking shop. A participant said: "There is a real need for guidance on how they are formulated. There is potential for them to be so much more than they are at the moment. At the moment they are just looking at reports and driving strategy forward."
It was crucial that the boards had wide representation, from service users to acute trusts, managers and a range of private providers. "Somehow we have got to find a system. It's about a shared strategic purpose," said one contributor. There was real concern that the boards will fail if their control is put solely in the hands of managers: "When clinicians and doers – the users and the providers – get together they can drive things forward," said a contributor, "if the doers aren't involved it won't happen." (See more)
© 2012 Guardian News and Media Limited
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