Prof Gerald Wistow's presentation

1. Local Authority and NHS Integration:
another lost opportunity?
GERALD WISTOW
HEALTH AND SOCIAL CARE INTEGRATION IN
THE NEW POLICY LANDSCAPE
SHA/SPA SEMINAR
Y O R K U N I V E R S I T Y , 1 2 TH O C T O B E R 2 0 1 2

2. Outline
 What is the problem?
 How do we recognise it?
 Does it matter?
 Everything‟s going to be different now, isn‟t it
 We understand the problem and know what works
now
 Face the facts, it‟s never been fixed in over 50 years
 We‟re trying the same old solutions…….
 And the new landscape is a large part of the problem
 We might be forced to find a different way…..

3. If integration is the answer, what is the question?
 How do we achieve better outcomes and experiences
for people whose needs span different professional
and/or organisational boundaries?
 What kinds of care and support models will deliver
such outcomes and experiences and for whom?
 Who is responsible for ensuring the delivery of those
outcomes, experiences and services and how are they
held accountable?
 What are the implications for national hierarchy of a
commitment to strengthen local networks?

4. Integration today
While many people told us of excellent care, we heard
alarming stories, particularly from the most
vulnerable, of poor access, falling through gaps between
services and being unable to understand how to navigate
their way through the convoluted „system‟. We heard from
people who had experienced delays and come to harm.
The universal feedback was that the current system is
fragmented and all patients, regardless of their
circumstances, want a more joined‐up and integrated
health and social care service, planned around their needs
(Field 2012 p.9).

5. Integration today
„Sadly……..we have been told repeatedly that the system, as
it stands, often does not deliver the integrated package of
care that people (with complex problems) need. It doesn‟t
deliver their desired outcomes either………There are often
wide gaps between services…. The often inefficient and
unreliable transitions between services result in
duplication, delays, missed opportunities and safety
risks…………and we know the recent scandals in
hospitals, home care, and care homes will not go away if we
don‟t change the way the system works.‟
(Integration Future Forum 2012)

6. Integration today
 „the development of each service was usually
considered in isolation, and it could not be said
that there was an overall plan for the
development of services for (older people) in any
of the authorities studied‟
 The local authority associations …….warned that
if they were not able to meet the extra expenditure
needed to expand their services, the Minister‟s
hospital plan would be imperilled‟

7. Integration Today
the document frankly expressed the rising tensions
with local government over what the (SHA) claimed
was ‘bed blocking’ and the ambiguous status
of………….‘large numbers of relatively active
patients’ (who) were occupying beds ‘which are
needed for the admission of urgent cases’ due to
failure to provide suitable accommodation
elsewhere. . ..
Gorsky 2012

8. We need it even more today
 Less hospital centred care and support systems
with proper investment in community networks and
informal care, together with shift to prevention, early
intervention, wellbeing and independence
 Social determinants of health: causes of the causes
 Strategic commissioning: address Dilnot‟s
suboptimal balance of national spending; service re-
configuration; reduced support costs; shifting
responsibilities and resources
 Personalised commissioning: choice, control and
joined up services from community and personal budgets

9. Everything will be different now…..
 Enhance role of local government in health and overcome
NHS „insularity‟ by
 leading on local health improvement and prevention (DPH)
 joint strategic needs assessments (JSNAs)
 joined up commissioning of NHS services, social care and health
improvement through HWBs and JHWS
 Strengthening local voice
 Transfer of £7.5bn from the NHS to councils over four
years to help NHS meet the „Nicholson challenge‟.
 £2bn pa to fund LA public health functions
 Introduction of stronger LA leadership role and more local
democratic accountability for first time since 1948

10. …….or perhaps it will be the same?
 Long line of initiatives to design new frameworks for
integration, each beginning with recognition that the last
had limited results
 „Despite repeated attempts to “bridge” the gap between
the NHS and social care……..little by way of integration
has been achieved over this 40 year period‟.
 Some success: contribution to closing long stay hospitals
and creation of islands of good practice often despite „the
system‟
 Can the latest statutory framework succeed where others
didn‟t?

11. Do we ever learn?
In all the debates about reorganising the structures of
central administration, local government, health
services, social services and finance, the first need is to
decide what it is hoped to achieve by the changes to be made.
Then and only then, can useful discussion take place on how
to achieve it. If it is hoped to achieve more effective planning
for the health and social services it is doubtful how far
structural changes of the kind being discussed will help to
achieve this aim.
Sumner and Smith

12. The collaboration paradigm
 Statutory duties to work together
 Coterminous boundaries
 Coordinating structures producing joint plans
 Financial incentives
 Permissive powers and limited accountability
 Bridging organisations rather than integrating
mainstream businesses
 Means not ends, structures not cultures

13. What helps?
 No silver bullets (but plenty of fool‟s gold)
 Knowing the question before the answer
 Common purpose before structure
 Outcomes before mechanisms
 Structure and agency
 Relationships and time
 Local and national leadership and accountabilities
 Power to move resources as well as technical
competence

14. Time to Face the Facts?
 Consistent weaknesses raise questions of systemic
failure and fitness for purpose
 Implementation deficiencies or flawed design?
 Both: institutions of structure, process and culture
create the spaces within which implementation is
conducted with more or less skill, creativity and
commitment
 Those institutions, in turn, are rooted in decisions at
foundation of NHS and 1974 reorganisations
 Institutions of NHS and local government designed to
be different and separate not similar or integrated

15. ……… but we always knew it was sub optimal
 Organisations primarily based on
 „Skills of professionals not needs of clients‟
 A place, local variety and functional coordination
 The service, national uniformity and functional
specialisation
 Coterminosity „an attempt to get as near as possible to the
advantages of…..unification by creating “two parallel but
interacting structures” (Joseph)
 A „miserable middle way‟ (Crossman)
 Need outward looking „community governance‟ (Stewart)

16. Opportunities Lost
 Re-assurance about competition and markets
 The Treasury and Management win the battle for
credibility and control
 The NHSCB re-centralises with commissars for every
CCG
 HWBs as a crucible for integration but not the location
for system leadership and steering (the „guiding mind‟)
 If agreement is not possible at the HWB?
 Existing arrangements are disrupted and dismantled
 CSOs are service not place based
 Is it really possible to strengthen vertical and horizontal
accountabilities simultaneously?

17. The source of continuing problems?
GP consortia, working individually and together, will
provide the engine for the commissioning system
locally, assuming statutory responsibility for
commissioning the bulk of services.
Consortia will need support and direction in order to
carry out this critical role effectively and providing and
shaping that support will be the central role of the
NHS Commissioning Board.
The Board will be confident about leading change at
scale – not through top down diktat, but neither being
shy about claiming a leadership role.

18. Different options emerging
 Single accountable officer: Health Committee and
Scotland
 Part of CCG budgets lodged in LAs
 Integrated purchasing through LAs integrated
providing through FTs (Burnham and SHA)
 Place based, community budgets
 Coordination through market mechanisms
 NHS as LHS: less insular, playing a fuller part of
the local family of public services or a single-
purpose, nationally controlled service;

19. Thank you
gerald.wistow@btinternet.com