Picture it: Andy Burnham, George Osborne and Norman Lamb get stuck in a lift. What do they talk about? Going by their recent speeches, integration of health and care might be a good place to start. It’s the focus of Andy Burnham’s ‘whole person care’ policy, George Osborne’s £6bn ‘Devo-Manc’ devolution, and Norman Lamb’s desire to merge the national budget for health and care. So what’s the prospect of these words becoming reality
Let’s rewind a decade. On joining the Department of Health in 2005, my first job was to ring up a number of folk in local authorities and PCTs leading efforts to integrate health and care. What I heard then I’ve heard a hundred times since: integration of care is hard, it takes time, and without constructive, trusting relationships within and across organisations, it’s nigh on impossible.
Fundamentally, whether care becomes more integrated – like whether any aspect of quality improves – rests on those people delivering it. As such, in looking at any integration initiative we need to use a ‘people test’ – how will national policy help individual staff deliver better care – to judge whether it’s likely to succeed or not.
It’s something I don’t think national policy makers often do well. As we explore in our Constructive Comfort report, in trying to effect change the tool of choice for policy makers is the organisational ‘prod’. Whether this is a blunt target or a crafty payment incentive, the aim is to externally try and get organisations to change their behaviour. Using this approach, the prodder cares not for how change happens – that’s the business of the prodded – their role is to stand back and set the framework.
Such an approach isn’t necessarily wrong; targets in particular have contributed to delivering significant improvements in specific areas. However, relying on such an approach is limited in at least two respects.
Firstly, it needs – but often fails – to start with a recognition of the environment in which staff are working. If you want staff to better join up health and care, they need the time and the ‘headspace’ to think about how best to do it. The NHS Staff Survey gives a fairly comprehensive picture of the environment facing staff and it’s not particularly pretty. In 2009, 52% of staff in NHS organisations were working additional unpaid hours but data for 2014 (published last week) show this is now 61%. In 2009, 28% of staff said that they had felt unwell over the last 12 months as a result of work related stress, for 2014 this is now at 38%.
This leaves us with the obvious question: regardless of prods or structural changes, where do we expect NHS staff to find the time to focus on improving care integration? Either more staff are needed (but we’re seriously strapped for cash), or we reduce the expectations placed upon them (but no sign of politicians looking to relax targets), or they need to work in a different way (but that requires the time to think in the first place). Something has to give.
The second flaw to the prod approach can be the lack of support following in the wake of the directives. This takes us back to my first job: if the major barrier to integration is often relationships, why are we not investing time and energy in relationship training for health and care staff? One option is for politicians and policy makers to use what lies behind successful change as their guide to what national bodies need to do to best support local change.
Let’s just look at one aspect, data and analytics: we currently have no meaningful national data on how individuals experience integration of care. So local areas are not able to use data to understand how well they are currently doing, whether they’re improving, or which other areas they could learn from. This is a huge gap in the way national bodies can support local change, and is only being addressed at glacial speed (see p45 of the NHS Outcomes Framework 2015/16: Technical Appendix).
However, there are some causes for optimism. The Integration Pioneer programme, and now the Forward View Vanguards, are built on the premise of shared learning and support – both peer-to-peer and national-to-local. Early indications from Pioneers have been that they’ve found this approach helpful; 268 areas couldn’t have applied to be Vanguards for nothing.
As such, I have mixed feelings about the recent integration announcements. I’m excited about the ‘Devo-Manc’ arrangement, not because it could be a prototype for how health and care could be integrated in other areas, but because there is obviously genuine willingness and commitment by local leaders to work constructively together for the benefit of their population. If Manchester succeeds, it’s highly likely to be because of these relationships, not because of the new governance arrangements. I’m not particularly keen on fiddling with Whitehall budgetary accountability as suggested by Norman Lamb. It’s well intentioned and while it’s not harmful in itself, it will be if it diverts people from more useful measures which focus on supporting staff. The same can be said of whether all local budgets should be merged: could it be helpful? Potentially. Would it be worth the amount of administrative reshuffling and organisational navel-gazing it would require? Highly unlikely.
Whoever wins the election, expect to hear speeches in early May about how the new government will take integration to the next level. However, if they really want to support integration of care rather than simply announce a catchy new initiative (remember the Integrated Care Pilots?), return to the people test: understand the pressures staff are under, what they need to drive change, and set about supporting them in whatever way they can.