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The faith of the integrators
Article Type: Editorial From: Journal of Integrated Care, Volume 20, Issue 2
I am starting the Editorial of this retrospective special issue to mark the journal’s 20th anniversary with two personal stories which go back even further in time. The idea is to illustrate what has changed and what endures. The Editorial is also used to introduce the individual articles commissioned from expert commentators, most of whom have written for the journal throughout its life. Since the journal has existed to promote user-focussed collaborative care, the common theme is why has integrated care not already become the standard model of provision in the UK?
For a few years before I left home for university in 1964 I played cricket for my village team. We had a fixture against the staff of a long-stay hospital on the outskirts of the neighbouring city. My father drove me there, into a magnificent parkland setting with an elegant stone-built mansion at its heart, the hospital. Needless to say, the facilities for cricket were all superior, a far cry from the places we normally played. As the match started, spectators turned up in their droves, the patients of the hospital. To a teenager, they looked very odd: ill-dressed, making noises rather than speaking, some with frightening appearance, and most wandering aimlessly. They wandered onto the pitch of course, only to be rather harshly shooed away by the hospital staff playing in the match. One poor man was so frightened by my father’s dog that he practically collapsed.
25 years later, I led the closure of a similar hospital. One day, I was taken to a building away from the rest of the hospital surrounded by a massive barbed-wire fence, Colditz style. I was being told in a thinly veiled fashion that these particular patients could never be cared for in the community. The patients here were barely dressed at all, one standing catatonically against the fence and others behaving aggressively to one another with no supervision. The staff were sitting together indoors around the TV set watching horse racing, smoking and reading newspapers. When I later reported my despair at this to the committee planning the hospital closure, there was an altercation with the trade union official in the group who stormed out, incensed at my apparent lack of understanding. The union was opposing the closure plan. A few days later he telephoned me to apologise, having now seen the situation with his own eyes, adding that he felt ashamed to call himself a nurse. These NHS facilities have gradually disappeared, and the new era was ushered in following the White Paper Caring for People, when this journal also began its life. The government called for a “mixed economy of care”, and this rapidly developed. Last year, we had the excruciating revelations by Panorama about cruel treatment of residents at Winterbourne View, a private sector nursing home. Plus ça change, plus c’est la même chose?
Also around the time I went to university I visited someone in another local hospital, a bleak set of buildings in a bleak location again on the edge of town. I knew this to be a psychiatric hospital. The patient I was visiting was one of my parents’ best friends, a lively and funny lady whose company I loved. I found her in an awful building, the sort I came later to know as a “back ward” in the NHS. She had become an incoherent shell of a person, stricken by dementia in her 60s, with the ward a terrifying place to be. Had this been taking place after Caring for People, these facilities would no longer have existed in the NHS, and she would furthermore have been paying for her own care in a private sector home … although subsequent legal action has forced the NHS to pay the costs of such “continuing health care”. Nowadays, every effort would be made to care for her at home, supporting her husband in the task. That is progress.
Of course, in the intervening 40 years the number of people with such frailty has increased vastly as our lives have lengthened, but our capacity as a society to provide consistent and compassionate care can still be found wanting (Age UK, 2011).
For a really distinctive and innovative take on the impact of prevailing separatist instincts, do read Ed Mitchell’s piece for this special issue as Legal Review columnist.
Believing in integrated care
In a sympathetic study of practice of psychological therapy, social casework and similar interventions (The Faith of the Counsellors), the social psychologist Paul Halmos (1965) pointed out that, in the absence of any evidence that they produced any benefit to recipients, practitioners have very commendable faith that their consistent application of care and attention to people will be helpful. Whilst subsequent research has now indicated what works best, the general point is well made that a determined belief in something is often necessary to bring about change in complex situations.
Similar faith, based on common sense rather than evidence, was shown by national policy makers who began around this time to see that functional connections between government social programmes were needed to address changing demands on public services from a changing society, as Gerald Wistow has pointed out in his article in this special issue. The joint approach spawned more specific proposals, e.g. the Committee on Child Health Services (producing the Court Report, 1978), and the Warnock Committee which considered special educational needs from an holistic perspective, its report leading to the 1981 Education Act. Court recommended multi-disciplinary “district handicap teams” but, despite warm words all round, they were never extensively implemented. Warnock’s broad picture was also narrowed during implementation, with the service becoming fundamentally an education responsibility, with schools struggling to negotiate extra inputs into the lives of the children and their families. Just this week, 30 years on, the current Prime Minister has been under pressure from dissatisfied parents of children with special needs.
Why is it, after 40 years of encouragement of collaborative working in the face of mounting evidence of the poor quality and inefficiency of contemporary forms of service delivery, including clear customer feedback about the drawbacks of having to find their own way around fragmented services, that agencies and professions can hold on to their established powers, responsibilities and routines in their mainstream work? It is as if governments have lost the knack of securing full implementation of their ideas and policies (a theme picked up in the conclusion of Rob Greig’s article in this special issue about personalisation and integration). Or is it that the difficulties and complexities of organisational change daunt people so much that only those that really believe in integrated care will go the extra mile to secure it?
The faith of the integrators has now been fortified by an international evidence base, which while not gold standard, has a certain authority about it (Ham et al., 2011). This special issue opens with two articles looking at the evidence base and how it has been developing. Ailsa Cameron and Rachel Lart reported on their pioneering systematic review in this journal about ten years ago, revealing the paucity of studies able to report outcomes, and highlighting the many hindrances to progress. But knowledge of what is likely to bar progress at least helps people to plan how to overcome the barriers, and the influence of their work has been apparent. Alison Petch’s article comprehensively discusses more recent evidence and its impact, analysing movements of the “tectonic plates” of evidence, policy and practice. We also look forward to the updated systematic review which Cameron and Lart will be undertaking this year.
Prior to Caring for People and the introduction of the purchaser/provider split in the management of health services, the idea of competition in a market for care services had no traction whatsoever. There was an all-pervasive public sector culture, augmented by certain voluntary sector provision, with private sector health care reserved for those few people with insurance or private means, and a surreptitiously growing market of private sector residential and nursing home care, exploiting a loophole in the social security system which allowed publicly funded residents through the door. (There was even a story that a junior minister had unthinkingly allowed the loophole to be exploited in the rush to clear his in-tray immediately prior to going on holiday.) It was certainly a costly decision, which caused the government of the day to commission Sir Roy Griffiths to find a solution. In an act of supreme irony, he recommended that local authorities (loathed by the Thatcher administration) should be given the responsibility for curbing the growth in the use of care homes and the associated financial burden. Councils were also to stimulate a local market in other forms of care and ensure a mixed economy of provision. “Self-funding” entered the vocabulary, and the increasing number of people with the means to pay have come to be able to exercise choice – at a price generally higher than local authorities would pay, however. Private sector home care agencies have flourished, and many local authorities ceased to provide care services of their own over time. With an increased number both of individual purchasers and providers you have the essential elements of a market. Even with the numbers of purchasers increasing further via the introduction of “personal budgets”, there is nevertheless still some doubt about the power frail individuals, often at times of crisis, can really exercise in this new market, especially over standards of care.
The oddest thing about this was that there was no requirement on the NHS to do anything similar: NHS providers have been edged towards competition, but mainly with each other, and there is a question about transaction costs, and about the reality of consumer choice – trusting your local NHS provider is a powerful factor for patients, and in many places it will be more convenient not to shop around. There has also tended to be a rumpus first if private companies have been given opportunities to enter the market (even very recently, with Circle trying, and eventually managing, to take over an NHS hospital), and second if an NHS service opts to leave the family. The NHS is a minefield for politicians, and caution has ruled. There is therefore no extensive mixed economy of healthcare – creating an asymmetry with local authorities which has perhaps made integration of health and social care less attainable?
A key question has been whether the two flagship national policies of integration and competition are compatible? At first glance they appear different paradigms for achieving quality and efficiency: choose one or the other. In Bob Hudson’s article in this special issue there are even hints that this preacher of the faith of integrated care is concluding that it is all getting too difficult. However, the Future Forum, set up to calm nerves over the Health and Social Care Bill, has gone the extra mile and can be seen to have the faith of the integrator (NHS Future Forum, 2011). Also, the idea of competition, not between fragmented individual providers, but between formally integrated systems has now been promoted by the Kings Fund and the Nuffield Trust (Goodwin et al., 2012). Let us hope that the conundrum can be resolved, with decisive leadership from the Secretary of State.
What will the best total system of primary, social and secondary care look like, and who will emerge to market it in your town?
The NHS and local government taboo
For 20 years this journal has tried to look broadly at integrated care, encompassing services for children and adults, housing, leisure, the independent and public sectors, primary, community and secondary health care, etc. But its distinctive focus has been on health and social care collaboration, which is in effect about local government and the NHS. Both have felt the effect of a centralising tendency in national politics over recent years, with targets, standards and performance management. Since the general management revolution in the NHS, also inspired by Sir Roy Griffiths, the NHS has come to demonstrate a rather brutal top-down style of business. With less discretion available to local government, the question arises why health and social care for adults have not been pulled together centrally, with a single budget, single set of statutory responsibilities, single performance management regime, etc.? This would bring people together at local level in a united mission. In its absence, an handful of individual believers in integration have had to do their own thing at local level, often in the teeth of opposition, e.g. in Herefordshire, North East Lincolnshire and Torbay (Smith and Ham, 2010). It would have helped get policy into practice.
There are credible explanations for this. For many years there was distaste in councils for the lack of local democracy within the NHS, which had been ruthlessly put in place during the Thatcher years. This created barriers at the top, even if at practice level people could work together well. This has probably diminished now, but it may have left a risk that the opportunity for a greater local government influence over health matters currently being put in place by the coalition government may be less warmly welcomed than it should be in some places. And the lack of sufficient understanding and experience of the health service in both councillors and managers may harm the chances of successful implementation of Health and Wellbeing Boards and the Public Health transfer, not to mention joint working with GP commissioners. This is where local government leaders ought to be thinking big. It is the only way to challenge the centralising tendency of NHS management.
Put this together with the lack of understanding (often fear) of local politics in the culture of NHS management and the risks of continuing separatism are multiplied. It is a shame that, instead of abolishing PCTs, they were not somehow merged into local government. This cannot have been beyond the wit of strategists in the Department of Health, especially when it had become well established by agreement in one place (Herefordshire) and would have been pursued in other places had not the imposed changes to the NHS machine overpowered them. Somehow local government always has to be the weaker partner. There is a taboo, probably reinforced in medical circles nationally.
I am grateful to the writers who have contributed to this special issue, and I trust readers enjoy the experience of reflection. Maybe deeper understanding of what has happened in the past will avoid the repetition of mistakes in the future, as the philosopher George Santayana warned? The current climate is more favourable for integrated care than has ever experienced, and it might be possible to progress further in the next five years than in the last 20.
In our next issue watch out for a forceful case being made for service providers to organise themselves to determine local models of integrated care as Accountable Care Organisations, and for commissioners to let them get on with it whilst concentrating on setting outcomes.
Peter ThistlethwaiteJournal of Integrated Care
Age UK (2011), Care in Crisis: Seven Building Blocks for Reform, Age UK, London
Goodwin, N., Smith, J., Davies, A., Perry, C., Dixon, A., Dixon, J. and Ham, C. (2012), Integrated Care for Patients and Populations: Improving Outcomes by Working Together, King’s Fund & Nuffield Trust, London
Halmos, P. (1965), The Faith of the Counsellors, Constable, London
Ham, C., Imison, C., Goodwin, N., Dixon, A. and South, P. (2011), Where Next for the NHS Reforms? The Case for Integrated Care, King’s Fund, London
NHS Future Forum (2011), Summary Report on Proposed Changes to the NHS, Department of Health, London, Chairman Professor Steve Field
Smith, J. and Ham, C. (2010), Removing the Policy Barriers to Integrated Care in England, Nuffield Trust, London