Health and Social Care Integration: Healing the Fractures?

In this blog IPC Associate Consultants Dr Melanie Henwood and Philip Provenzano reflect on some of the enduring challenges to health and social care integration and offer an analysis and way forward grounded in mature system relationships and leadership.

The fault line between health and social care has been problematic from the beginning in 1948, with the existence of two largely separate systems. However, over the years there has been an unseen and covert shifting of the boundaries between health and social care.  People who once would have been cared for by the NHS are now the responsibility of the social care system, and people who would have been in long-stay wards in earlier times are now in residential and nursing homes, funded either privately or through adult social care.

Social care funding is an anomaly, which makes it very different from other parts of the health and welfare system.  If we were designing the NHS and social care system from scratch today, it is very unlikely we would choose something that looked and operated like this. It is little wonder that reorganisation has been an almost constant feature of the NHS under successive administrations, each seeking to improve efficiency and strategic coherence.  

Integration

Whatever the difficulties for individuals in navigating and understanding the operation of two parallel but separate care systems, the organisational challenges are also substantial.  The ‘grey’ area between health and care creates problems of coordination between services, especially at points of interface – notably around discharge (transfer of care) from hospital to home. 

How best to manage these organisational tectonic plates shifting around each other has for decades been approached through governance and coordination machinery; from Joint Finance and Joint Care Planning Teams, through Joint Strategic Needs Assessments, to Pooled Budgets, and latterly through the Better Care Fund (BCF) and Integrated Care Systems. But these have all been post-hoc attempts to smooth boundaries rather than remove them.

Research exploring joint working will typically point to the problems created by different cultures and by different accountability structures between the NHS and local government.  The factors that are likely to make joint working more successful often include the interpersonal and informal variables such as a history of good working relationships forged over time, the development of trust and respect and understanding of areas of interdependence. Even when systems have the benefit of such shared history and successful endeavour, they are likely to have different understandings and approaches to framing problems and solutions.  A caricature is that the NHS tends towards quantitative metrics (patient numbers, flow, length of stay etc), while social care will introduce a qualitative lens to scrutinise what difference service inputs make to a person’s experience, independence, satisfaction and wellbeing.  It is not the case that one approach is right and the other wrong, but that both are needed and are hard to blend.

The Darzi investigation of the NHS commissioned by the incoming Labour government was clear in its conclusion that “the NHS is in critical condition”, and detailed the key reasons for the crisis but made only passing mention of social care which was “outside the remit of this investigation”, and referenced only insofar as it impacts on the NHS (primarily in people being delayed in hospital for want of social care provision in the community). 

Understanding where problems lie has long been the focus of different strategies and interventions, ranging from punitive centrally imposed fines to the more targeted input of the BCF and associated diagnostic support for capacity and demand planning.

“Healing the Fractures?

Improving shared performance will require more than an understanding of the current state of play and is likely to include targeted support and individual coaching to facilitate transformational change. What is key to this – but often overlooked – is the importance of leadership that genuinely embraces the whole system of health and care.  Without support for a strong, shared culture, success relies on fragile personal ties. It depends on motivated individuals fighting against the current.

So, organisational support may need less of a technical fix, and more focus on the softer skills of relationship building and trust development.  In short, are we missing the obvious? We seek seamless health and social care, but need to better understand individual and organisational dynamics.  The challenges of this for the system seeking integration are significant. It will require a major shift from the NHS, which is typified by hierarchical structures and accountability. Genuine collaboration needs to respect and engage with the participative and more democratic styles of local authorities that are embedded in local communities and citizen experience.  The tensions between these two approaches is growing. Local communities or ‘place’ interests risk being trumped by larger and more powerful ‘system’ interests.  The two do not have to be opposed, but ensuring there is synergy requires a deliberate, strategic and genuinely collaborative model across and within health and care.  Ignoring these real challenges, or not seeing them as part of the leadership role, may explain why the ‘only connect’ mantra is still recited, and often fails to deliver.

The Darzi themes, which will inform a forthcoming 10-year health plan, could help. They emphasise care closer to home and developing a ‘neighbourhood NHS.’  But, there are no guarantees this will genuinely integrate systems. As long as social care is seen as a means to improve NHS productivity, the fissures and cultural dissonance between the two systems will continue to present major challenges to truly seamless or holistic care. 

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Contact the authors

Philip Provenzano
Associate Consultant
Dr Melanie Henwood
Visiting Research Fellow

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