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Silos in - Silos out

20 December 2017


You wait forever for a report on the integration of health and social care to come along – and then three come all at once! (Actually, this is not quite the case – as it seems that at times we are beleaguered by reports – although limited change results). The last week has seen the launch of the first ever Joint Health and Care Workforce Strategy – Facing the Facts, Shaping the Future – You can see my thoughts on this less than joined up reporthere. The second is the Kings Fund report on Enhancing Health Care in Care Homes: Systems Leadership in Action – highlighting the efficacy of the Vanguard model and the very real potential for roll out. Then the final one is the CQC interim report on their Local Systems Review

At the time of writing the report, the CQC were part way through their review of 20 localities across England, which you may remember were announced in the Spring Budget 2017. The methodology for review is laid out, and has been developed in partnership with people who use services, their carers and guided by SCIE. This report makes for interesting reading, as it does in a sense get to the nub of the challenge that the ‘joint’ workforce report (cited above) so aptly demonstrated. If you approach integration through an organisational lens of partiality – you will end up with integration in name only. The CQC report finds this to be the case in the majority of the areas they have reviewed to date, finding that “The whole person approach to flow of people through the system is being overshadowed by the drive to meet individual organisational targets.”

As ever, with these reports, there is a helpful list of what works well. Although you are left with a strong sense that this list was significantly shorter than the ‘what needs to change’ list. What was particularly interesting was the strong messages about how the integration of health and social care cannot be seen in isolation. The report features strongly on the role of prevention, and indeed the role of the wider Voluntary and Community Sector in providing essential support for people to remain independent and outside of the ‘integrated’ health and care provision .

I think that both of these areas are critically important and reflective of the systems leadership approach that these reviews have taken. However, as essentially the report is without commentary on the localities previous actions, it does not acknowledge what has been lost, which may have made this a very different story to tell. For example, it talks about the under-utilisation of voluntary, community and social enterprise providers and their importance to people who use services in offering preventative services and services to support people to live the life they want. However, does not address the large scale cut backs that many established preventative services have received, nor indeed address how they are to be funded in the future. The ability of small organisations to flex and change in relation to demand is of course the supposed ‘backbone’ of our economy – but all organisations need a core and long term future to enable that resource flexibility to be sustained.

The report also shines a valuable light on the current paucity of transfer of data between organisations, or within the ‘system’ and the very real impact this has on an individual’s life. This timely reminder comes at a time when major shock waves around the security, ownership and transfer of individual’s data are being felt throughout social care with the advent of new General Data Protection Regulations and the focus on Information Governance and Cybersecurity.

Perhaps one of the core explanations offered as to why the whole ‘system’ is currently adrift is because different parties are still focussing on achieving their own organisational outcomes. The report calls for measures to “enable and incentivise health and social care partners to establish aligned objectives, processes and accountabilities.” These suggested measures include agreed metrics to measure system performance, and the importance of funding flows that reward integrated behaviour – and recognise the role of longer term contracting approaches to sustain commitment to large scale transformation. This includes, the investment of systems in ‘out of hospital’ services, keeping people away from acute services and firmly within their home of choice. STP’s are seen to potential in this strategic alignment – but their role and influence is variable.

Finally, to the people involved. Joint work with people who use services and their carers to inform local system strategies works – but not enough is being done to ensure these are coproduced. Carers are not being adequately supported, and the inability of those across the health and care system to accurately and efficiently share information about the changing health and care is inexplicable and frustrating – in equal measures. The other people factor is around the workforce. Interestingly the report calls for a national focus on joint health and social care workforce strategies across systems – I sincerely hope that there is significant reform to the existing document that will make this laudable objective a more meaningful reality. Particularly as the systems review recognises the enhanced level of skills that are needed by those working in residential settings to provide safe, responsive and effective care to people with increasingly complex health and wellbeing requirements – a clarion call for joint learning and development across the system.

So – much work to be done – and of course a New Year in which to do it! What will 2018 hold? Green papers, systems reviews, vanguard completions, Brexit negotiations, and – of course - a partridge in a pear tree!

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