Care England’s chief executive Professor Martin Green says it’s time to shift the dial in the conversation about what true health and social care integration means

We have been talking about the benefits of health and social care integration for a long time, and it is important to remember there have been many attempts to deliver this, all of which have failed to a greater or lesser extent. I can remember when we had joint appointments between health and social care; we also had co-location where health and social care staff were working out of the same office. After this came a range of structural changes. We have had health and wellbeing boards, primary care trusts, and clinical commissioning groups, and now we are in an era of integrated care systems. What’s clear from this history is that people don’t learn from it, and every time the system goes into a spasm of reorganisation, there’s so much hope for a change in how services are delivered. Yet, much of this hope is dashed by the reality of what happens on the ground.

Shifting the dial
One of our biggest challenges is that nobody understands what integration means. There is so much talk about organisations, systems and processes, yet integration should be about people and outcomes. We need to shift the dial from talking about the NHS, local authorities or care providers and focus on the experience of people using the service. There also needs to be more acknowledgement about integrating systems with vastly different resource bases and public perceptions. The NHS swallows up vast amounts of taxpayers’ money and there’s little left for social care. Another challenge is that the different bits of the system have widely different statuses and knowledge among the public. For 70 years, the public has been fed a diet of how wonderful the NHS is, which is in marked contrast to the little public recognition of social care.

An integrated approach to measurement
It’s also impossible to integrate systems with significantly different success measures. If we are going to have truly integrated health and social care services, we need to be clear that everyone has to be measured in the same way. The current system requires an integrated approach to measurement. In some cases, the measures of success in different parts of the system are incompatible and in conflict with one another. If you take the example of integrated system, we see little attention given to the measures of success across that system.

If you take the example of measures of success in the NHS, these are often tied to activity when they should be about prevention and enabling people to live well. This is brought into stark contrast where the measure of failure for a local authority adult services director may be the admission to the hospital of a citizen, yet this is a measure of success in the NHS, where measurement systems tend to work on activity rather than outcome.

I think we should work on three very high-level sets of measures. First, we should measure the person experience; we need to know how the person experiences the service and be clear that it delivers what they need and want from the intervention. Second, we must measure the outcomes of an intervention. Every single intervention, whether it’s health or social care, should have a clearly defined and measurable outcome, and any intervention should leave people with a better outcome than would have been delivered had they not been in contact with health and social care. These measures can be very broad and include medical treatments, improved wellbeing, or better capacity to manage their lives and long-term health conditions. The third measure is about the effective and efficient use of human and financial resources. If we were to recalibrate services on the basis of the most effective use of resources, there would likely be a significant transfer of money from health into social care and into prevention. It is sad that in all the attempts to deliver a happy life for the citizen, and in many ways to address only two of them, and forget the other aspects of people’s lives, is to miss the point of an integrated approach.

Community integration
It is also essential to think about how people live their lives, and we often have conversations about integrated systems which begin and end with health and social care. While these are very important aspects of an integrated approach, people live their lives within communities. So real integration would go far beyond health and social care and would think about housing, transport, community services and connectivity with community family and friends.

All these elements lead to a healthy and happy life for the citizen, and in many ways to address only two of them, and forget the other aspects of people’s lives, is to miss the point of an integrated approach.

Game changer
Despite my fairly healthy cynicism about previous reorganisations, the move towards integrated care systems could be a game changer, but it has to be accompanied by a significant amount of culture change within the current
system. If history has taught us anything, it’s that just by changing structure, you don’t necessarily change the outcomes or transform the system. It’s often said that culture eats structure for breakfast, and we see this so graphically illustrated in health and social care reorganisations. We often see structures, names and organisations changing, but we find huge numbers of the same people just shunted into different jobs with little or no focus on how they are going to deliver something differently and how they are going to change their approach to be fit for purpose in the 21st century, or indeed, how they will be measured in terms of their success.

I distinctly remember meeting senior leaders in South London’s health and social care sectors many years ago. I was in a room with 30 people and I asked them to introduce themselves and tell me about their job and immediate previous roles. What was so evident was that every single one of those people had related to this new system and social care staff were relegated to second place. There is a desperate need to have an integrated system, but I’m concerned that we’re not learning from previous experience, and I don’t see the culture change that needs to happen to deliver a different system fit for purpose in the 21st century.

I am still waiting for an ICS with a clear grasp of integrated success measures and integrated approaches to value and outcomes for citizens. When I see that, I will believe that we might get to where we need to be. As demographic change starts to happen and there are more pressures on our system, we cannot afford to fail, and we cannot afford to do what we have always done because we will not have the financial or human resources available for business as usual. This is our moment for a paradigm shift; I only hope some are brave enough to take it.