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Richard Humphries: A year is a long time in the politics of integrated care

10 Mar, 14 | by BMJ

richard-humphriesWhen Andy Burnham set out his vision for “whole person care” at The King’s Fund last year, few would have disagreed with his crisp summation of the need to move towards one service that meets people’s needs as opposed to the three very different existing services—the NHS, mental health services, and social care.

The Labour Party went on to establish an independent commission led by Sir John Oldham to consider how this vision of whole person care could be achieved. Following this, the government set out its own stall with a new national collaboration framework for integrated care, featuring a programme of 14 co-ordinated care pioneers, and a £3.8 billion Better Care Fund—a pooled budget to be spent locally to provide better support at home and earlier treatment in the community.

The report of the Oldham Commission, published this week, will influence Labour’s final policy position on health and social care ahead of the next election. It has received a generally warm welcome, and offers a cogent analysis of the need for a new model of care and ways of working. The report offers a compendium of proposals, many of which reflect best practice already in place in some areas, such as care co-ordination, information sharing, a shift to outcomes-based commissioning, and the concept of the “locality pound” (instead of separate budget silos). The commission’s thinking on capitation based funding for long-term conditions and complex needs reflects much of The King’s Fund’s thinking about the need for new contracting and payment mechanisms to incentivise integration. And the proposal to replace section 75 regulations with new regulations that assert the primacy of collaboration over competition could bring some much-needed clarity to a murky and confused aspect of current legislation, but will mean negotiating the minefield of UK and EU competition law.

Inevitably some reaction has focused on the proposed role of health and wellbeing boards as system leaders that would produce a collective commissioning plan with CCGs—stopping short of transferring CCG commissioning budgets as envisaged in Andy Burnham’s original plan for “whole person care.” Setting aside the Kremlinology of Labour party politics, the distinction is more about means than ends. The most effective health and wellbeing boards will end up playing a key role in overseeing the total health and care commissioning budget anyway—but will have done so through partnership with CCGs, not takeover—exactly the route the Oldham Commission proposes and that our research findings suggest.

Achieving integrated care on the ground is hard to do—and in many ways the current reforms have made it harder. But the bigger policy fault line is still about money. The Oldham Commission correctly recognises the need for a consensus on the scope of future services and how they are funded and proposes an “independent national conversation backed by all of the political parties”—but after the election. Can we wait that long to start this debate? The NHS remains a universal service that we all use and receive free at the point of use and that is paid for collectively through taxes. Social care on the other hand is heading in the opposite direction—means-tested, rationed, and used by fewer people (20 per cent less in the last three years alone). Nearly half of people needing long term care have to pay for it all themselves.

As more of us are living longer with a mixture of health and care needs that straddle two fundamentally different approaches to entitlement and funding, the need for a different settlement designed for the 21st century has never been greater. That’s why The King’s Fund has established an independent commission chaired by the economist Kate Barker to consider how the two systems can be better aligned and how fairer, more consistent entitlements to health and care services could be funded in the future. Its interim report, to be launched in early April, outlines some of the hard choices this raises and offers options for change, ahead of its final report in the autumn.

Although all political parties agree about the importance of integrated care as an end, willing the means to achieve it is another matter. The gathering storm of financial pressures in the NHS and local government means there is no time to lose.

Richard Humphries is assistant director, policy at The King’s Fund

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