Better health and social care integration?

A fundamental question hangs unanswered

11 June 2018

Today the Health and Social Care Select Committee proposes a number of steps to improve patient care by better joining up services, but a fundamental question hangs unanswered. What can be done practically to support staff to turn the principles and ideas of integrated care into reality?

In the Health Foundation’s evidence to the inquiry, we argued that new contractual and organisational forms – such as those created to support the New Care Models vanguards and Sustainability and Transformation Partnerships (STPs) – and revised governance and accountability frameworks are important for creating the right incentives and removing barriers to change, but will not, by themselves, be sufficient to change the way that care is delivered.

The inquiry’s report reflects this evidence, recognising that structural and policy changes alone are not enough to lead directly to more holistic, joined-up and coordinated experiences of care for patients. It argues for ring-fenced transformation funding, and notes that ‘rather than changing administrative structures, the sort of change required to design and implement integrated care is often at a micro-level and concerns how frontline staff work together.’

Helping staff accelerate changes

So alongside vital additional funding, what might help staff to accelerate changes to how care is delivered? A model developed at Sheffield Teaching Hospitals NHS Foundation Trust with support from the Health Foundation – and cited in the committee’s report – illustrates a possible way forward.

The Discharge to Assess model of care enables patients who are medically fit to leave hospital to have their support needs assessed at home by a health and social care team. It operates at the interface of NHS-funded hospital care and local authority-funded social care, and the committee rightly suggests it would be better supported by pooled health and social care budgets.

However, a look back at the origins of the Discharge to Assess model tells us that the fundamental enablers of this innovation were not primarily technical in nature, but relational. As described by consultant geriatrician Tom Downes in a recent talk, the model was developed by health and social care staff in Sheffield coming together each week in a ‘Big Room’, facilitated by skilled coaches using rigorous quality improvement methods, to discover a new way to deliver care, through many small tests of change.

How does the Big Room method work?

Last week, I saw the power of this method for myself, when I had the privilege of attending a Big Room at Imperial College Healthcare NHS Trust. Imperial is one of the sites that is taking part in the Health Foundation’s Flow Coaching Academy programme, which aims to replicate the method developed in Sheffield in health care providers around the UK.

The Big Room brings together all staff involved across a pathway. The room I observed had doctors from medical and surgical disciplines, nurses, managers, data analysts and information technology providers. They used a structured method to identify opportunities for change and agree plans to test them. Grounded in real patient stories and experience, there was no jargon, no acronyms, no helplessness about what was beyond their control, but a collective commitment to identifying and trying out new ways to improve care for patients.

The diversity of perspectives enabled rapid identification of decisions and trade-offs; the data and information technology were there in service of the clinical change, with analysts, managers and IT specialists working directly alongside clinicians, as part of a shared goal to improve care for patients. It is these kinds of methods, skills and forums that can enable teams to discover practical solutions that can work in their local context.

A clear vision for delivering integrated care

So, a central test for the move towards more joined-up services is: is there a clear vision and understanding of how STPs and related initiatives such as integrated care systems will lead to and facilitate staff to make changes in the way care is delivered? And is there space and support available to enable those who will need to design and deliver these changes alongside the essential business of continuing to deliver day-to-day patient care? If not, there is a risk that new plans and structures are put in place, but continue to support fragmented and historic patterns of care.

If staff are to successfully lead the redesign of health and social care services we know is required to meet people’s needs now and into the future, it is essential they are given support and space to come together to discover and deliver change effectively. The kinds of capacity and capability building described here are vital to these efforts, alongside sufficient funding, and investment in the health and social care workforce.

With the Prime Minister set to make an announcement on a longer-term funding settlement for health, our analysis shows that to meet increasing demand and make some improvements health spending needs to increase by 4% in real terms per year for the next 15 years. And over the next five years spending needs to increase at a faster rate of 5% per year to address the backlog of funding problems, and make meaningful progress on priorities such as waiting times, staff shortages, and improvements to mental health services. This will allow the NHS to access resources that will enable investment, including in support for staff, to make the changes that are needed now to transform care for the future.

Will Warburton (@willwarburtonHF) is Director of Improvement at the Health Foundation

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