Emerald Group Publishing Limited
Copyright © 2011, Emerald Group Publishing Limited
Article Type: Editorial From: Journal of Integrated Care, Volume 19, Issue 4
Although our June Issue ultimately appeared in a new format consistent with Emerald’s journals style, this is in effect the first Editorial I have written specifically under our new regime. I am wholly reassured that the change of publisher will not threaten continuity; and I am confident that my perception of differences in emphasis and possibly direction will engender welcome developments over time. There is a confident and challenging team at Emerald and I expect that their influence will filter through into the future pages of the journal. Changes being perceived by readers are not going to be merely cosmetic, therefore, and I personally welcome the chance to develop the focus and quality of Journal of Integrated Care (JICA).
But this is also a moment for retrospection …
This journal can trace its origins to the reform of community care in the UK flowing from a White Paper Caring for People, which culminated in the NHS and Community Care Act 1990. The reforms were triggered by financial pressures on the government of the day, arising from loopholes in the system of social security which had been found: these enabled people lacking their own funds to be admitted into independent sector care homes with full state funding, and without any form of professional assessment of needs. What had started as tentative testing of the system by entrepreneurs in the care home sector became system wide exploitation, later recognised by acute hospitals as a neat means of securing early discharge, and by long-term NHS institutions as a means of securing sustainable community care alternatives for their patients. The White Paper speculated fearfully on the longer term financial consequences of this unintended policy – which now look miniscule when compared to the later bail-out of the banks. The Act consequently ensured that state funding would only be granted after assessment by the responsible local authority, which would always consider alternative forms of care and support in the home, working within a set budget. This seemed like a win/win situation: control of burgeoning spending, with innovative care in the home. Subsequent guidance and legislation have consistently emphasised collaboration between local government and the NHS as fundamental to effective implementation.
There is enough in the previous paragraph to provide themes for myriad policies, articles and books; and the debates continue. In particular, in England, we have just received the report of an important commission on the division of responsibilities for funding of long-term care. The context is increasingly complex, especially as demographic and economic forces have evolved.
As Editor of this journal over the entire period, I have tried to ensure that JICA specialised to some degree in the health and social care partnership – which was reflected in the title of the Act and was heavily promoted in guidance, e.g. on joint assessment, hospital discharge. From the start, however, we have also been open to wider perspectives involving housing, leisure, community development and the NHS in its own right. Eventually, the title of the journal was changed from a focus on community care to a new one reflecting the core interest in integrated care. This wider concept is now in common parlance nationally and internationally, and the subtle shifts in responsibility between individual, carer, community, local authority and state and their expression in policy, funding, politics, organisation and management have brought rich material to our pages.
With much heavier emphasis from the current coalition government on integration within care services, JICA seems to be in a good place currently. This will be highlighted for you in the arguments put forward in our lead paper in this issue by the distinguished analyst of policy and practice in recent decades, Gerald Wistow.
What particularly excites me is that we face the prospect of widespread experiment in models of integrated care which need to be followed in detail and critically compared. Policy has given the researcher and evaluator live subjects:
A large number of Hospital Trusts taking community health services into their organisation.
A few Hospital Trusts taking on social care services as well, under a partnership agreement with a local authority.
A good number of Mental Health Trusts taking on community health services, some of which may include social care.
Some Community Health Services transforming into independent social enterprises owned by their staff, some of which may include social care.
Some Community Health Services seeking to become Foundation Trusts in their own right.
The prospect of a new wave of primary care-led initiatives which could transform the organisation of services close to the patient/service user.
There will be other options which I have not mentioned, including Care Trusts, which are themselves reviewed in this issue by Robin Miller et al. at Birmingham University.
The fundamental test will be whether the current White Paper, Bill and reorganisation will be “a means to an end, and not an end in itself”, as the WHO famously defined the purpose of integration. The WHO saw the ends in benefits to the patient: easier access, and improved quality and satisfaction. History suggests that a combination of political self-interest or expediency, and management limitations will make it hard to concentrate fully on public outcomes. We will see … but, the pause in the progress of the Health and Social Care Bill whilst the big battalions of professional interest fight for pre-eminence is no encouragement. One interesting example here is the article here by Anna Coleman et al. at Manchester University which shows how limited, despite official rhetoric, are the prospects of full public engagement in shaping the future. On the other hand, a small comparative study of local NHS performance through the lens of partnership and integration, presented here by a Public Health Team in Devon, shows what outcomes might be achieved by local innovators.
The message I have is that JICA will actively seek reports of evaluative work in these areas of major experiment. We need help from local actors to make this a reality; and the journal can evolve creatively to accommodate this. Please come forward with your ideas.
The integrated care legal review
One innovation regular readers will notice this time is our new column written by Ed Mitchell, a well-known commentator on community care law whom we are delighted to welcome. We bade farewell to John Dow in the previous Issue, and Ed will provide continuity in legal inputs to JICA, although in a new format. Ed has commented as follows:
In my legal column for the JICA, I hope to be able to continue the tradition established by John Dow, to whom I would like to pay tribute, of setting out clear, practice-focussed analysis of the latest legal trends impacting on integrated care. My aim will be to illuminate the legal principles that lie beneath headline legal outcomes with a view to providing clear legal reference points for the study and practice of integrated care. To do this effectively, I intend to draw on the different legal and practice perspectives I have gained as a lawyer advising on social and health care in central and local government, as a drafter of secondary and primary legislation in those fields and in my current roles as General Editor of the Journal of Community Care Law (Arden Davies Publishing) and as Legal Adviser to Community Care magazine (Reed Business Information). Any feedback or queries about the columns would be much appreciated: firstname.lastname@example.org.
Readers will be aware of another significant legal development; the Law Commission’s recently published recommendations on the reform of adult social care law. The implications of that for integrated care will be the main topic of the next column.