Integrated health and care services have been the goal of central policies and local discussion for some time, and moves to devolve health budgets to areas such as Manchester and Cornwall are giving integration yet more impetus. At the Health Foundation, we’ve been thinking about approaches to improving quality in the health and social care worlds, and how they might be bridged for integrated care.
The differences between the two sectors are stark. Social care is provided by thousands of unique, often small private and third sector organisations. NHS providers are mostly state run, large organisations, holding a lot of sway with local commissioners. NHS providers are generally seen as too big to fail – social care providers can and do go out of business. The NHS average wage is £29,754, while most homecare providers struggle to pay more than minimum wage.
These differences are also evident in the approach taken to supporting quality improvement. In health, there is an implicit assumption that central government has ultimate responsibility for quality. This is encapsulated in former health minister Aneurin Bevan’s phrase “if a hospital bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall”. Several health secretaries have repeated this phrase when recently asked about their role.
Despite various attempts to remove the formal responsibility of the secretary of state, the national, political and quasi-religious status of the NHS means that when health providers are failing, governments act.
The Health Foundation has argued that there is too little support for NHS providers, and national action has focused too much on levers such as payment systems and performance management. Even so, the national stance has consistently been that responsibility for provider transformation goes beyond providers themselves – encompassing their commissioners, and requiring regional or national support programmes.
In social care, the story is different. The reverberations of bedpans once reached town halls, but now they struggle to be heard by even the most perceptive councillors. For various reasons, the purchaser-provider split genuinely transformed how social care is delivered, accelerated by the need to provide the choice and control for people using services. This continues in the Care Act’s market shaping duties, albeit with a duty to have regard to “the importance of fostering continuous improvement” in a diverse care market.
As more care is being delivered by the voluntary and private sector, improvement support in social care has been increasingly seen as the responsibility of providers themselves. It is largely given through good practice guidance provided by organisations such as the Social Care Institute for Excellence, Think Local Act Personal and Skills for Care – the most recent example being the joint website Care Improvement Works, mapping resources against regulatory requirements. Direct support is generally only available on an individual consultancy basis.
Where the delivery of statutory functions (such as assessment, care planning, review and safeguarding) has remained largely the work of the local authorities themselves, peer review has played a significant role, and is viewed positively by those involved.
So in health there is recognition that improvement takes support beyond the boundaries of providers, and in social care much less so. Why is this? A large contributor could be ownership; a feeling that we should support publicly owned organisations to improve (hospitals) but privately owned organisations (care homes) should sort themselves out. This perhaps explains why support for general practice in health is a much overlooked area. However, the idea that resources to support change will be feeding into profits seems laughable in the current financial climate.
Scale also has a role to play. Health has a strong national and regional component, whereas social care focuses very much on the market within a council. And a third issue may be understanding of outcomes. More transparency in performance in health may mean more attention is paid to it. In social care, there has been very little information to judge quality of care on until recently.
The Five Year Forward View, devolution to city regions and the implementation of the Care Act dramatically changed the health and care landscape, and demand joined up thinking about how to improve quality. Where will the reverberations be heard from integrated provision, multi-speciality providers and local government run hospitals?
Health and social care can learn from each other. The focus on peer support and learning in social care could usefully be picked up by health, including support for commissioners. And in social care, more support for providers could allow them headspace to look beyond the day to day, and regional coordination could facilitate learning and spread of innovation. Some aspects are being explored, for instance through the recently announced pilot of peer reviews for Better Care Fund activities. It is important that the supportive stance of peer review is carried through to implementation.
Beyond mechanisms for improvement, the task of bringing together very different cultures should not be underestimated. Support for both those leading change and those providing care will make success much more likely. If we are serious about integration, we should confront and discuss our cultural assumptions about improvement at a national and local level, and take the best from health and care’s different approaches to supporting improvement.
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Felicity Dormon is senior policy fellow at the Health Foundation and Patrick Hall is practice development manager (policy) at the Social Care Institute for Excellence.
