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The Government's plans for integrated health and social care make a lot of sense. But what about the impact on the NHS as an institution? Is its integrity under threat?

Despite widespread agreement with the aims of health and social care integration, serious concerns have been expressed by many healthcare professionals, from psychiatrists and mental health nurses to occupational therapists. They're not just worried about increased short-term pressures on already stretched services. They also fear that devolving control to local authorities may undermine the core values that have defined our healthcare provision since 1948.

"We want everybody who uses both health and social care services to have integrated care - services that work together to give the best care based on a person's personal circumstances." So says the Government's web briefing on health and social care reform. It's an aspiration that's almost impossible to take issue with. However, when it comes to putting theory into practice, things are not as straightforward as they might at first seem. Despite assurances from Care and Support Minister Norman Lamb that NHS provision will remain unchanged, further integration of health and social care inevitably means a blurring of the lines between NHS and local authority responsibilities, and consequently of their respective budgets. This could have a significant impact, particularly on healthcare professionals whose responsibilities often straddle primary and support care, such as occupational therapists, physiotherapists, speech and language therapists, learning disability nurses and mental health nurses.

A matter of principle


It's not just about changes in demarcation and working practices. At stake is one of the defining principles of Aneurin Bevan's vision for the NHS: free at the point of delivery. It's the key focus of a recent article for the Community Care website by Professor Luke Clements, an adviser to the parliamentary select committee that scrutinised the draft Care and Support Bill. He points out that, while the NHS maintains its founding ethos of free healthcare for all, regardless of ability to pay, the social care service is means tested. "If health obligations are shunted into the social services' siding," he says. " We undermine the NHS and start charging people for these services - with all the attendant impact this has on health and socio-economic inequalities."

There are also concerns about whether the benefits of integration are being overstated. In a recent survey of Institute of Healthcare Management members, more than half of respondents said they didn't believe that integrated care would take the pressure off the NHS. In a 2013 press release the Department of Health is unequivocal about the benefits of integration: "Coordination will see better care and support, fewer people falling through the cracks and a drop in patients needlessly stuck in hospitals." However, in The Evidence Base for Integrated Care, produced by the highly respected King's Fund and Nuffield Trust, authors Nick Goodwin and Judith Smith argue that integrated care doesn't evolve naturally and relies on 'strong leadership, professional commitment and good management', as well as an ability to break down systematic barriers. They claim there is "no evidence that clinical and service integration in England is any more or less likely to succeed than in countries without a purchase-provider split, such as Scotland or New Zealand".

As care delivery is shifted from hospitals to community settings, there is a danger of over-reliance on unqualified carers to do the work that's currently done by healthcare professionals. A 2013 survey, carried out by the National Nursing Research Unit and Employment Research Ltd for the Royal College of Nursing (RCN), shows that the number of district nurses has fallen by about 40% over the last 15 years. In a statement released in June 2014, the RCN went further, predicting the complete extinction of district nurses by 2025 unless urgent investment is made in the service. Much of the work done previously by these key health workers, particularly with the elderly and disabled, is now the responsibility of unqualified carers.  An obvious concern is that other primary care services such as physiotherapy jobs and occupational therapy posts could be similarly affected. Sending healthcare professionals such as physiotherapists and occupational therapists out into the community is a costly business and, as they take on more responsibilities from hospitals, there may be pressure on community care providers to rationalise services.

Feedback is vital


There's little doubt amongst stakeholders in health and social care reform about the importance of consultation. It's seen as vital that implementation of the new Care Act is informed by input from the people who will be expected to make it work, including frontline healthcare professionals. The good news is that the Government seems to be aware of this and has been acting to make it happen. As well as a general consultation on the Care Act via the Department of Health website, which closed on 15 August, there have also been other calls for feedback. For example, through the College of Occupational Therapists, members were asked to provide comments on the draft guidance and regulations. The College provided written evidence to a cross-party committee of MPs and peers, which has made key recommendations to the Government, particularly relating to the free provision of equipment and adaptations.

Similarly, to help clarify its response to the 2014 Care Act, the British Medical Association (BMA) has been gathering case studies of health and social care integration from doctors' perspectives. Their current position is that better outcomes for patients can be achieved without the kind of high-level budgetary or structural integration which might threaten the integrity of the NHS. Instead, in a briefing note issued in May 2014, they advocate simply a 'refocusing of attention' on how healthcare and social care professionals can work together 'to ensure patients and service users experience as seamless a service as possible as they move through their treatment and care'.

In the same briefing note, the BMA also questions the cost savings predicted to be delivered through health and social care integration by organisations such as the Care Quality Commission (CQC): "The BMA have been sceptical about the cost savings which can be achieved through integration, believing that any potential savings will likely not manifest for many years, if at all. The BMA does not believe full integration of health and social care (structures, budgets and staff) is either necessary or desirable. The current structures should be retained, maintaining separate services, and existing mechanisms to facilitate coordination between health and social care should be used more widely to plan and deliver joined up local services."

The Government clearly sees things differently. In a 2012 press release, the Department of Health gave an example of how integrated health and social care can deliver cost savings: "By working together as a team, physiotherapists, speech and language therapists and dietitians can help stroke survivors regain independence faster and leave hospital and go home sooner. This could save the NHS over £7 million every year."

In November 2013, Care Minister Norman Lamb announced that pioneering health and social care integration initiatives were being launched in 14 areas across England, from Cornwall and the Isles of Scilly to South Tyneside. In one of the areas, Greenwich, it's claimed that over 2000 patient admissions were avoided due to the work of a team made up of nurses, social workers, occupational therapists and physiotherapists. In another, South Devon and Torbay, getting in touch with a social worker, district nurse, physiotherapist and occupational therapist now requires just one phone call, rather than several.

Money matters


As for the thorny issue of funding, almost inevitably there's some controversy here too. The June 2013 Spending Round announced the creation of a £3.8 billion Integration Transformation Fund, now referred to as the 'Better Care Fund'. It's described as 'a single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities'.

However, as The King's Fund points out in their evidence summary, Making Best Use of the Better Care Fund, this is not new or additional money:  "£1.9 billion will come from clinical commissioning group (CCG) allocations (equivalent to around £10 million for an average CCG) in addition to NHS money already transferred to social care. For most CCGs finding money for the Better Care Fund will involve redeploying funds from existing NHS services." It's worth remembering that local authorities remain under severe financial pressure because of budget cuts, so are unlikely to be in a position to 'take up the slack'.

In July 2014, the Department of Health launched a tender for a 'rigorous longer-term evaluation' of the Integrated Care and Support Pioneers Programme in the context of the Better Care Fund, any subsequent funding arrangements and wider policy innovations. The evaluation will be for up to five years from spring 2015. In addition, Monitor, the Department of Health watchdog, will be considering how it can help enable integrated care 'where this improves the quality (outcomes or efficiency) of services or reduces inequalities of access or outcomes' (Department of Health guidance, updated 8 September 2014).

Many health professionals will be hoping there is time for the results of this evaluation and monitoring to be taken into account before we reach the point of no return on the integration path. The future of the NHS as we know it could be in the balance.

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