Integration of health and social care needs financial incentives, experts say

BMJ 2012; 344 doi: (Published 03 May 2012) Cite this as: BMJ 2012;344:e3185
  1. Nigel Hawkes
  1. 1London

After years of talk, is integrated care about to become a reality in England? Three politicians from the leading political parties offered a mixed message at a meeting at the healthcare think tank the King’s Fund on 1 May.

As befitted the parties, the Conservative and Liberal Democrat representatives, Sarah Wollaston and Judith Jolly, were cautiously positive that the new Health and Social Care Act might advance the cause. But Norman Warner for Labour, a health minister in the previous government, identified a host of familiar obstacles.

Local activists, who had been given a leading role by the act, would never have reformed the NHS by themselves, said Warner. Direction from the centre was always necessary. And although a few examples of integrated care could be discerned—Torbay, Herefordshire, and Southwark were among those he mentioned—it had taken 20 years to get this far.

“So I’m sceptical about the ability of the NHS to do it,” he said. “Maybe the Berlin Wall between health and social care will crumble, but I wouldn’t bet the farm on it. The NHS finds it hard to integrate primary and secondary care, never mind social care.”

There were, Warner said, very few incentives for overcoming the barrier of differing managerial and professional cultures and very few consequences of failing to do so. With no cash rewards for doing it, and when things got tough, as at present, “managers retreat and shunt costs across the barriers to someone else.”

Was the new act, for all its warm words about integration, really set up to achieve it? Warner doubted it. The government had rejected amendments to the bill that would have introduced a proper definition of what integration actually meant and would have imposed on the health secretary and the National Commissioning Board the duty to report annually on how integration was progressing. Neither amendment would have damaged the bill, but they had been rejected nevertheless, which he saw as a missed opportunity.

Jolly said, by contrast, that integration was “threaded through” the bill and was now in statute. But she foresaw difficulties in making it happen. Torbay, famous for integrating health and social care, was a small area where the primary care trust and local authority were coterminous and that had a single acute hospital. Clinical commissioning groups would cover several local authorities and several hospitals. Incentives would be needed, with rewards for quality and outcomes and not for volume of activity.

Wollaston, whose constituency includes Torbay, said that, unless funding of social care improved, integration would fail. Torbay had succeeded in shifting money out of the NHS budget and into social care, but to achieve that more widely was a huge challenge. She recommended the idea of a single commissioner for health, social care, and housing. The bill could have wrested power from national politicians, but instead it had given power to local politicians. “And which local politician will risk making any changes to a local hospital?” she asked. “And how will GPs deal with the press when they try to do it? They’ll feel very uncomfortable.”

Some support for this view came from the floor. Ken Kizer, who engineered major changes in the US Veterans Administration in the 1990s that embraced an integrated care model (BMJ 2012;344:e3178, 3 May, doi:10.1136/bmj.e3178), said it had been “anything but painless.” When the Canadian province of Ontario had attempted a similar reform, he had warned against retaining local control. His advice had been ignored, and the evidence was that the reform had not been as successful as it might have been.

Mark Newbould, chief executive of Heart of England NHS Foundation Trust in Birmingham, an acute trust, said that the system was stacked against integration, because it incentivised hospitals to increase their own activity. He had just negotiated a block contract—“though I’m not allowed to call it that”—to try to get round this problem.


Cite this as: BMJ 2012;344:e3185