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‘Heads up’ on the State of Integration

3 July 2018

‘Beyond Barriers: How Older People Move Between Health and Social Care’ is a key report from the CQC, builds on interim reports of the locality reviews carried out by CQC and shows that we are in a pretty sorry state when it comes to our ambitions for integrated health and care. The case studies within the report show just how vital it is that we deal with this now. For example - the case of Mr Singh, who lives at home with dementia and over the period of a week, 42 out of his 56 weekly visits were provided by different care workers - is vitally important to hold onto. Whilst within the ‘system’ there are lots of explanations of ‘breakdown’ that can be used to explain this situation, the basic fact is that this is untenable going forward - for everyone involved. 

The report states that “Health and social care organisations should work together to deliver positive outcomes for people and ensure that they receive the right care, in the right place and at the right time”. 

Really! You don’t say. Anyone would think the value of integration hadn’t been mooted, never mind legislated for - yet the report would suggest that progress is patchy in the extreme, and that people remain the casualty of the fractured system. 

The report does provide us with a series of recommendations - and I will have a look at a few of them in more detail:
  1. Encouraging and enabling commissioners to bring about effective joined-up planning and commissioning
  2. A new approach to performance management
  3. A move to joint workforce planning
  4. Better regulation and oversight of local systems.
Joined up working
The drive to facilitate joint planning and commissioning has been central to some of the more significant architectural changes within the health and social care landscape. The report is clear that the focus of much of that joint commissioning should be on prevention, and yet we know from the recent ADASS budget survey that the coffers have run dry for prevention - so how will this be achieved? The report also highlights the potential of the ‘perverse incentive’ in the current relentless political focus on the Delayed Transfer Of Care (DTOC). Recognising that whilst it is absolutely right we enable people to return to their home as soon as they are safely able to, what we really need to be incentivising is the work around preventing unnecessary hospitals admissions. Interestingly, the area that social care providers involved in the recent Vanguard programme, demonstrated tangible improvements. 

As a passionate champion of prevention, I am left wondering how many stories of protecting people upstream do we need to hear - how many images of cliff tops, ambulances and fences do we need to get this message the priority it requires in the joint planning agenda. 

In order for joint planning and commissioning to be a reality, there needs to be a significant jostling of chairs to make room around the table. The report highlights how poor localities have been at accessing and building on the support of the Voluntary and Community Sector, and certainly this has been the experience of many NCF members who have struggled to get the voice of provision heard within the new vehicles for change such as Sustainability and Transformation Partnerships and as a result are often left out of key decisions about commissioning and integration until it is too late. 

I was delighted to see CQC return to their focus on workforce, which they highlighted so effectively in the State of Care Report 2017. The report notes that “Joined-up care also requires a workforce equipped to move between health and social care. Workforce planning needs to create the skills and career paths that allow people to work flexibly across the system as services evolve over time to meet the population’s changing needs.” Again that frustration around our current state of play, where we still have learning and development programmes that operate in relative silos, and enable people to come out at the end of their training largely unaware of how integration needs to work in practice, and crucially their role in facilitating it. 

Regulation of Local Systems
“I’ve started – so he’ll finish!” This is very important - and perhaps one for posterity. It is of note that this is probably the last public document that Sir David Behan CBE will have his name to as the Chief Executive of the CQC. It provides a clear signal to the new CEO Ian Trenholm, of the need for CQC and other regulators to work together to shine a light on how the ‘system’ works in practice - away from the arm words of policy and legislation. The report notes that “Currently, performance is measured in individual organisations, working separately… But if we are to encourage and recognise efforts to collaborate across the health and social care, then we also need regulation to look at the quality of care across whole systems.”

And finally…
The report ‘Beyond Barriers’ once again shows we know how to do it - there are lots of examples of where system change has been achieved - but sustainability and scale remain in question. This is not a new story - so what will make this report different - so that it is not consigned to the narrative of useful information that we chose to ignore. Well in true style, David Behan gives us a massive clue, in his final statement:

“The question that remains is whether leaders working locally and nationally have the bravery and conviction to lead the charge.” 
Sir David Behan CBE (Mic Drop)

However, the timing of this report is also absolutely critical. Whilst the report has an intrinsic value in its own right - it is the timing of this report that is so crucial for social care, and it is welcomed that the CQC has added its substantive voice to provide a set of strong and powerful messages for the forthcoming social care green paper, workforce strategy and the Comprehensive Spending Review. In addition, the advent of a new CEO at CQC who may wish to take forward a new dynamic for the organisation. The clamour for CQC or someone to take up the mantle of regulating commissioning may mean that there is real scope for this report to pack a punch. 

The CQC talks about health and social care as ‘two halves of a whole’. However, I have also heard much quoted in recent weeks the phrase that health and social care are ‘two sides of the same coin’ - whilst I appreciate the neatness of this analogy to commentators - it suggests a simplicity to the system which this report blatantly exposes. It has been used tirelessly in recent weeks to justify the postponement of the social care green paper, whilst it waits for the ‘other side’ of the coin (the NHS) to publish their 10 year plan. The irony surely being that the publication of a detailed ‘plan’ versus a consultative document does not make a ‘balanced’ coin, and social care once again fears that in any future toss up for funding, the odds will be severely loaded. 

NCF would want to take this final opportunity to pay tribute to the work of Sir David Behan CBE who leaves the CQC this month. Under his leadership of the regulator, he has been a great champion of Social Care. It is of note that he has chosen this critical integration message, highlighting the roles of both social care and health as potentially his final public report.

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