As figures leaked to the BBC reveal the worst A&E performance figures in 13 years, a dissection by the National Audit Office of the stalled progress towards health and social integration lays bare government hubris and fictional promises of progress from within the NHS.
Integration takes many forms, including multidisciplinary teams making coordinated assessments of a patient’s care needs, services for a particular condition being brought together, and organisations pooling budgets and jointly commissioning services.
Governments and the NHS have been firing off integration policies since the 1970s. Recent ones include the 2010 announcement that £2.7bn would be transferred from the NHS to local government to promote joined-up working; the 2013 spending review announcement of the Better Care Fund, which resulted in health and local government pooling £5.3bn to integrate services and reduce pressures on hospitals; the launch that year of the Integrated Care and Support Pioneers Programme to make joined-up and coordinated health and care the norm by 2018; and the Five Year Forward View in 2014.
Every time ministers indulge in this sort of nonsense it undermines the credibility of subsequent attempts at reform
The NAO skewers the government on its failure to provide any evidence that integration delivers sustainable cuts in costs or hospital activity. An international study by the University of York in 2014 of 38 integration schemes in eight countries failed to find any robust evidence supporting claims of sustained cuts in admissions, yet ministers persist in creating the impression that integrating services will lead to costs falling out of the system.
The Better Care Fund epitomises the endless cycle of central money being tied to unachievable targets, which encourages local NHS bodies to make promises they have virtually no chance of keeping.
The fund aimed to save £511m in its first year, by cutting demand for hospital services. Everybody in the NHS knows that stabilising emergency admissions would be a huge achievement, let alone cutting them, yet local Better Care Fund plans played along with the fantasy that they could deliver a rapid reversal by promising total reductions of 106,000 admissions between 2014-15 and 2015-16, saving £171m. Admissions went up by 87,000, costing £311m more than planned. Furthermore, delayed transfers were supposed to be cut by 293,000 days; they went up by 185,000.
Every time ministers and NHS leaders indulge in this sort of nonsense it undermines the credibility of every subsequent attempt at reform. Cynicism takes hold, rotting belief that improvements can be made.
There were better outcomes for reducing admissions to care homes, and increasing the proportion of older people still at home 91 days after discharge, but these in no way compensated for the reversals elsewhere.
Damningly, the NAO points out that the three main barriers to integration – misaligned financial incentives, workforce problems and poor information sharing – have been flagged since at least 2003.
The failure to break down these barriers leads to the crazy situation where health and care staff can only succeed in working more closely together if they fight the very system that employs them. In any rational world, processes and structures would be set up to promote the goals you are trying to achieve, not obstruct them.
System bodging should be a compulsory training module for NHS and social care managers, as it is now a core requirement of the job. From STP governance arrangements to competition law to sharing patient records, astonishing amounts of time and money are squandered trying to find ways around the rules.
Overall, the drive to bring health and social care together is a well-intentioned mess. Countless integration cottage industries across the country are working largely in isolation from each other and semi-detached from wider work such as the STPs. Their work is based on poor evidence, effort is duplicated, and time and money is wasted fighting the system.
If integration is to have any chance of happening, government and the NHS central bodies need to focus relentlessly on removing the barriers to change, joining up disparate policy initiatives and gathering and disseminating credible evidence as to what everyone should be doing.
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Drive to bring health and social care together is a well-intentioned mess
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