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Integration or fragmentation: piecing together England's health and social care

Integrated care opinion piece by David Brindle

Tuesday, January 9, 2018

The analysis was damning if predictable: too many people are confused by having to move between health and social care services; care is too often fragmented, choice is limited and people are uncertain about who is coordinating action on their needs; many people worry about what support will be in place when they return home from hospital, or how their informal carer might get a break.

The verdict came just before Christmas from the Care Quality Commission and was based on the first six of a series of 20 “local system reviews” it is conducting, looking at how well health and care services work together at local level in England to support and care for people aged 65 and over.

But it could just as well have been written by someone listening to contributions at the packed and lively Respiratory Futures panel debate at the BTS Winter Meeting 2017, only days earlier.

Care is too often fragmented, choice is limited and people are uncertain about who is coordinating action on their needs
David Brindle

That debate, on the topic of whether integrated care can improve respiratory health outcomes, threw up encouraging – indeed exciting – examples of successful integration, especially in Leeds and Manchester. But the predominant picture that emerged was one very like that painted by the CQC, exacerbated by workforce shortages, financial pressures and systems running so hot that thinking integration comes second to keeping the show on the road.

Again, these concerns chime with the CQC, which identified three themes getting in the way of integration: shortcomings in how providers and commissioners work together; capacity, market supply and workforce pressures; and preoccupation with avoiding delayed transfers of care in isolation from the wider problems faced by local systems.

“In response,” said Prof Steve Field, the CQC’s chief inspector of general practice and integrated care, “we encourage all system partners to have a clearly communicated health and social care offer that responds to people’s local needs; to provide a stronger focus on wellbeing initiatives that can help people to stay out of hospital; and to address variation that can help inhibit people’s access and choice.” 

Sustainability and transformation partnerships – STPs - and fledgling accountable care organisations (ACOs - see Respiratory Futures’ excellent Jargon buster if those terms leave you none the wiser) are seen as key vehicles for delivering the kind of vision set out by Field.

But neither has found universal acceptance and ACOs in particular are seen by critics as a malign import from the US. Sir Bruce Keogh, NHS England’s medical director, was prompted over Christmas to issue a public reassurance that ACOs were not “the Trojan horse for privatisation” but “a bold attempt to unite a fractured system and stop people being pushed from pillar to post”.

With two separate legal suits being mounted to try to stop further development of ACOs, the stakes could scarcely be higher for the health and care sectors as we enter 2018 and prepare to celebrate the NHS’s 70th birthday.

David Brindle is The Guardian's Public Services Editor.