News / Piecing it together

Fundamental integration of health and social care in England is being discussed seriously, for the first time in decades. The government has fostered greater collaboration between the services and 2015 should see a step change in this with the introduction of the better care fund.

But rather than two distinct services with their own budgets shuffling up alongside each other to plan a limited amount of care, there are now calls for much greater integration.

In April, the King’s Fund’s Barker commission recommended that merged commissioners should control a single pot of money covering all care. The commission’s interim recommendations were made against a background of gathering support for some levels of integration.

While health and social care is already integrated in Northern Ireland, the Scottish government has legislated for greater health and social care integration through joint working between health boards and local authorities. In England, partnerships between clinical commissioning groups and local authorities will drive integrated services through the better care fund. The Welsh government has also pledged to integrate, though it too has rejected structural change as a means to deliver this.

In March, the Oldham commission (see box), set up by the Labour Party to review the future of health and social care, backed integrated funding and commissioning, though it ruled out immediate structural change.

And in his first speech as NHS England chief executive, Simon Stevens called on health and social care bodies to get on with integration, although he appeared to hint that further reform might be necessary in the future.

‘Fundamentally, we know we’re going to have to find ways of better blending health and social care for people with high needs,’ he said. ‘How best to do so is a debate we should have.

‘But as we do so, no one should pretend that just combining two financially leaky buckets will magically create a watertight funding solution. It’s going to take more than that. So my aim is that NHS England and our local government partners get going, this year, on supporting and testing some practical new models that don’t need structural reorganisation.’

The King’s Fund commission, led by economist Kate Barker, was firm about the need for reform of both the structures and the finances facilitating an integrated system. In its report, A new settlement for health and social care, it said that not only should there be a single ring-fenced budget for health and social care that is singly commissioned, but also entitlements should be more closely aligned.

Integration without reform would ‘simply be another “make do and mend” of two fundamentally different systems’, it said. And, with social care underfunded and the NHS seemingly heading for a short-term financial crisis, funding must be addressed sooner or later, it insisted. The lack of alignment in entitlements, funding and organisation between the two systems results in unfairness, poorly co-ordinated services and confusion for patients, service users and their families.

Commission chair Kate Barker said: ‘The current systems rub up against each other like bones in an open fracture. The lack of alignment between them leads to serious problems of co-ordination, with the NHS and local authorities battling over who should pay for what, and patients, service users and their families left confused and bewildered. This is not sustainable – we need a new settlement fit for the 21st century.’

But the interim recommendations bring up a number of practical issues, principally linked to the key difference between the systems – with the NHS largely free at the point of use and social care means tested. In order to align entitlements, the interim report asked whether social care eligibility criteria should be moved to the NHS model, making it largely free? Or should NHS services shift to the social care model, reducing the extent to which healthcare is free. While the latter seems almost unthinkable politically, the former would probably require more funds, it said. Where would this be found? From increased taxation? Higher charges for NHS or social services or both?

She acknowledged there were practicalities to address. 'This report is our stake in the ground. The prize we seek – a single, seamless health and social care system that offers equal support for equal need – is a significant one. This necessitates making choices about how to pay for a better system – hard choices that we must look squarely in the eye.'

NHS Confederation chief executive Rob Webster said the report was a valuable contribution to the debate on the value provided by health and social care services. There was a consensus that joined up or integrated health and social care services was essential in the 21st century.

He added: ‘This fits the needs of patients. A similar approach for health and social care finance could, in principle, help make this a reality.

‘There will be much to consider in taking this forward – from real-term budget allocations for local government reducing by 14% in the last four years, to the balance of risk across the health and care system, and the issues of charging for social care versus free NHS care.’

Graeme McDonald, director of local authority chief executives’ group Solace, said the divide between health and social care was ‘no longer fair, functional or sustainable’ and the Barker commission had set out a compelling case for change.

Association of Directors of Adult Social Services president Sandie Keene also welcomed the report. But she said: ‘We need further evidence that additional integration between the two services will provide the cost savings that some think it will. Integration alone will not address the key issues of equity and sustainability but is an important driver for change.’

It is likely that mandated pooling and commissioning of funds will be a key element of health and social care strategy over the coming years. The sums involved could expand if the better care fund is deemed to be a success. But even if the Barker vision of more integrated health and social care funding and commissioning does not happen, one of its main talking points could become a hot issue for the public. If health and social care bodies are successful in creating a seamless service through joint commissioning, could public pressure to make social care free at the point of use grow?