Plugging the gap between health and social care

Helen Birtwhistle says NHS and local authorities must work together to provide a seamless service

Social care is rarely an issue that hits the headlines. In the public debate, it is often overshadowed by its close partner health and the latest stories of hospital reconfiguration or waiting time targets.

While much has been made of financial pressures on the NHS, there has been less attention to how social care will cope with similar financial challenges. Both are facing real-terms budget cuts. Last year the Wales Audit Office said that social service budgets were facing real terms cuts of almost 2 per cent, while the NHS is preparing to make 5 per cent savings every year for the next three years.

National conference: Cardiff, 16 January 2013

Making sense of the NHS in Wales

Professor Ceri Phillips will be speaking at this important IWA conference on the future of NHS Wales. Other keynote speakers include Professor Marcus Longley, of the Institute of Health and Social Care, University of Glamorgan; Dr Stephen Monaghan, of Public Health Wales; Helen Birtwhistle, Director, Welsh NHS Confederation; Carol Lanyman Davies, Director, Wales Board of Community Health Councils; Tina Donnelly, Director, Wales College of Nursing in Wales; and Rachel Podalek, of the General Medical Council

For more information and to book download event flyer here

At the same time, both the NHS and social care will need to deal with rapidly rising demand due to the ageing population. In 2011 there were more than 430,000 residents aged 90 and over in England and Wales compared with 340,000 in 2001 – a 21 per cent increase in just ten years.

We should celebrate the success story that we are living longer. However, we also need to recognise the reality that this success increases pressure on health and social care services.

At a time when budgets are tight, it is more important than ever that NHS and social care organisations work together to provide an effective service. Experience shows that social care and health are so interdependent that savings made in one budget can simply transfer costs to the other.

There are indications that when people’s needs are not met by the social care system, they turn to the NHS. The impact is seen through increased demand for emergency and unplanned work, and delays in discharging people from hospital.

And sadly, it is the individual who suffers as they fall in the gaps between organisations. Too many patients stay much longer than necessary in a hospital bed while there are difficult and complex discussions about who should fund the long-term care package.

In Wales, there has been a strong emphasis on integration between health and social care over the last few years to avoid these sorts of situations occurring, and there are many examples of where health and social care staff have been brought together into integrated teams.

However, integration and seamless working on a widespread scale is something that has proved elusive. There have been any number of ideas and pilots, including pooled budgets, shared offices, integrated teams and joint appointments.

But there still remain many barriers that hinder completely integrated working across health and social care. Complete structural merging of the two functions has proved problematic, largely because of the fundamentally different governance arrangements between NHS and local authorities, with local government’s direct democratic accountability inconsistent with the more complex governance arrangements that exist in health.

The complexity of financial flows and the difficulties of separate IT systems are other reasons often given to explain why integration can be so hard to achieve. Encouragingly, some successful projects have shown there are ways and means around these obstacles without costly, time-consuming and distracting structural change. One project often cited as an exemplar is the Gwent Frailty Programme. This is designed to provide an alternative to hospital admission for older people at times of acute illness  and to enable people to leave hospital earlier.

All localities in Gwent have established integrated health and social care Community Resource Teams. These work with people with the aim of supporting them to stay independent in their own homes. They manage this by providing care at home, helping people return home sooner, and by speeding up the process of finding the right complex care package.

The programme was launched April 2011, but a lot of the groundwork was done in the months leading up to it. Joint work streams were created to look at information sharing around performance and evaluation to make sure that all aspects of integrated working were taken into account. There was recognition, too, of the importance of well-motivated and supported staff. A workforce work stream worked through the logistics of training, induction, team-building, and ongoing supervision and development prior to the programme ‘going live’.

It is an approach backed up by research by the NHS Confederation, which found that examples of successful integrated working have been brought about through creating the right culture, encouraging the right behaviours and setting the right values rather than formal structures.

It is something the Welsh Government will be looking at closely in the next year, as it seeks to introduce legislation on social services. The intention is to set up a legislative framework for more integrated services that could well include the use of pooled budgets – something that has been talked about in Wales for some time.

This legislation offers an important opportunity for Wales to lay the foundations for more effective and integrated services. Our aim should be to enable people to have a single point of access covering both health and social care, which they can understand how to navigate. Certainly, there is a clear expectation for local authorities and other public service organisations, including health, to demonstrate that they are working together.

Success will come down to strong local relationships and leadership and commitment from both the NHS and local authorities at the local level. We have an opportunity to get health and social services working together effectively on a widespread basis across Wales. Whatever the outcome of the Bill, integrated working is too important not to get right.

Helen Birtwhistle is Director of the Welsh NHS Confederation

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