Integrated care – what does it really mean? Slawit SOS lobby of Kirklees Council health scrutiny committee Tuesday 8 March, 3pm

Slawit Save Our Surgery is calling for a lobby of the Kirklees Overview and Scrutiny Panel for Health and Social Care at 3pm at Huddersfield Town Hall TUESDAY MARCH 8, for the meeting that starts at 3.30pm.

This meeting has the integration of Health and Social Care on the agenda which is highly relevant for what is happening with GP surgeries.

You’d think integrated care would simply mean finding ways to link up all the different services patients need  but it seems there may well be a hidden agenda here.

There is a dearth of evidence for the efficacy of integrated care, and there are anxieties that – given huge central government funding cuts to Local Authorities’ social care budgets – the integration of health and social care will mean the plundering of already inadequate NHS budgets to prop up local government services.

This is what’s happening as a result of the Better Care Fund – the main current vehicle for integrating NHS, social care and other public services.

Social care has been plagued for decades by cuts, outsourcing and piecemeal privatisation of services, leaving many staff on zero hour contracts and service users with 15 minutes sessions of care.The danger is that under local authority rules, integrated health and social care will mean that there will be means-tested charges for services rather than the NHS principle of services funded from general taxation.

The outcome may be a deregulated, local service – partly privatised, its social care component already 90% privatised – facing a meltdown in local authority finance, competing with other localities for patients and funds, with local pay and conditions for health workers, and all branded as “integrated”.

Lack of evidence for the efficacy of integrated care is outlined in various reports:

“Current policy is aimed at cutting the number of emergency admissions by providing more, better services outside hospital that can either prevent the need for hospital admission or offer the same care but in different settings. This is a common theme in initiatives for more integrated services, including the government’s Better Care Fund. But there is little evidence that this can be achieved.”

(Bardsley and others, 2013, cited in a Nuffield Trust briefing (NHS hospitals under pressure: trends in acute activity up to 2022), (p11)

A 2014 Health Service Journal review of the evidence for promoting “integrated care” out of hospital found that:

“a close look at the data highlights a dearth of evidence on the impact of integrated care”.

And, reporting on its Commission on Hospital Care for Frail Older People, the Health Service Journal (November 2014) stated:

“There is a myth that providing more and better care for frail older people in the community, increasing integration between health and social care services and pooling health and social care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.”

In written and oral deputation statements to the 22 Feb Joint Health Scrutiny Meeting, Save the NHS campaigners show that integration of health and social care threatens the survival of the NHS, by merging it with cash-strapped, means tested, largely privatised council social care and leisure services and a wide range of other local authority and central government public services.

Nowhere does the hospital cuts Consultation Document explain how the NHS principles of providing a comprehensive, equitable, universal health service for everyone who needs it, free at the point of need, are going to survive when merged into this cash-strapped, means tested, largely privatised system. Particularly come 2020, when it is predicted that central government grants to local authorities will be £0.

The  Consultation Document fails to acknowledge that, on p 136 of the Pre Consultation Business Case, the Clinical Senate says that that the Community Services Specifications for Calderdale, Greater Huddersfield and North Kirklees CCGs lack information about the primary care strategy, and because of this, it has “been difficult” to judge whether insufficient capacity and capability to complete and deliver the primary care strategy will scupper the community services programme.(Pre Consultation Business Case p 137/8)

The Joint Health Scrutiny Committee asked that the Consultation Document should address the Clinical Senate’s reservations about the proposals for the hospital services clinical model and Care Closer to Home.

Jane Rendle’s deputation statement (p17) to the 22nd Feb JHSC meeting focussed on the draft Consultation Document’s proposals for integration of health and social care, through the so-called Care Closer to Home scheme.

She pointed out that:

“The Clinical Senate were unable to certify that the Community Services Specification would generate the required quality of care because of its lack of local detail. The evidence cited in the latest draft Consultation Document does not rectify this.The Consultation Document case for Care Closer to Home claims there is a public preference for community-based care – but it doesn’t show that this is practicable or value for money.

“The only evidence given is that admissions to hospital from care homes that received Quest for Quality in Care homes support were 25% lower, in the year to March 2015, than from other Care Homes. Also that the length of stay was reduced by 26% saving £500,000. This was not a controlled trial and doesn’t take account of other differences between the two groups of care homes. By now there should be more data, better evaluated. To present the data in this way is not honest.

“Six personal stories of positive support add colour but are not evidence. The costs of these interventions are missing, as are the costs of scaling them up to the whole area served by the Trust. This makes it impossible for the public to give an informed opinion on Care Closer to Home.Primary health care is underfunded and struggling. The government is cutting public spending and the consultation document fails to show that the proposals will maintain the quality of health care, let alone improve it.”

Jane Rendle also highlighted the justifiable fear that the history of closing mental health hospitals in the 80s and 90s and moving mental health care into the community is about to be repeated.

Once the hospitals had closed, funding for mental health Care in the Community was whittled away, leading to inadequate care and no hospital back up. Today we have the disastrous situation that sometimes there is not a single available mental health bed in the country.But the Consultation Document makes no mention of this.

Why we need the NHS Bill

The NHS Bill legal briefing  on the Integration of health and social care makes it clear that this requires careful consideration, and ideally its own primary legislation (notonly regulations), as in Scotland.

The legal briefing gives a brief history of the original distinction between health and social care.

“The original distinction, which sought to balance the interests of hospitals and local authorities, was created by the NHS Act 1946 and the NationalAssistance Act 1948,and has been fairly described as “a fudge”.

“The broad formal differentiation was between free nationally – provided health services and means-tested locally-provided social services. Over time this fudge has been exploited in various ways to enable a shift from NHS-funded to means-tested local authority care, using policies such as Care in the Community, closure of NHS long – stay beds and NHS day care provision, and introducing continuing care criteria which enabled the NHS to discontinue NHS care by time limiting care or redefining eligibility.”

The NHS Bill legal briefing continues:

“There is much genuine concern that integration would lead to the provision of means-tested – and reduced -health services.

Changes proposed by the Bill in the location of functions through delegation do not extend to changes in the power to charge, and health services must remain free. We support the principle of free publically provided social care, but this is an issue which ideally requires further primary legislation.”

Sneaking in means-testing of healthcare through the social care/integration agenda is ONE means of restricting access to healthcare, as the NHS Bill legal briefing states, but there are other methods which are quite central to Tory thinking on health, and we need to show we’re alert to them, as well (and ideally, how the bill could address them).

One method of restricting access is geographically (ie, by income/poorer/richer areas),  by reorganising care out of local, easily accessed A&E/acute services, into different settings without an evidence base  (‘care closer to home’ – which might turn out to be less care/  further from home / lots of care nearby if you can pay for it).

Stop plans to make healthcare conditional on compliant behaviour

Another method, which also claims to be about ‘integration’, very worryingly underway and thus far little noticed by many NHS campaigners (though causing great concern to disability campaigners) – is cultural and administrative; it involves introducing the harsh culture of benefits conditionality into healthcare. This is about restricting access to healthcare to people on the grounds of non-clinically evidenced judgements made about their behaviour, be it addiction issues or not ‘looking hard enough’ for a job’.
gp surgeries not jobcentres.png_large

Integrating health with benefits  is being tried in Cornwall Devo, but also nationally in a range of different ways, as this article makes clear.

In fact, the stated aim of government ministers is basically to integrate benefits with EVERYTHING. Or, in other words, not so much ‘joined up care’ as  introducing that ‘undeserving’ narrative and punitive culture into all public services, from housing to health to transport, to kill off any ideas about universalism.

Also, we need to be very alert to how the social care and benefits integration sometimes wears the mantle of public health language about prevention – and how in reality is a total perversion of the ideas about progressive public health, ie social determinants of ill health – in the government’s eyes, it’s all the individuals’ fault, and the remedy is 100% stick, no carrot.

Anyway, to come back to thinking about the language we use in identifying the problem and setting out the Bill as a solution – restricting access one way or another is what it’s all about, of course.

The phrase on every councillors lips is ‘demand management’ – which in the context of health, they laughably spin as being about prevention/addressing social determinants, but in a context of severe ‘austerity’, is really about moving towards healthcare gatekeeping done NOT by your GP (who’s bound by professional ethics and public service ethos to put your best interests first) but by some private ‘health advisor‘ contractor hired by the council…. or perhaps by the team of private bureaucrats hired to manage your personal budget for you….

The bitterest irony is that this ‘austerity’ doesn’t save money, stores up costly social problems.. but it is PROFITABLE. The private sector can’t make a profit by providing comprehensive universal healthcare – the state is FAR better at doing that, cost effectively. But it CAN make a profit by segmenting healthcare recipients into people who live in nicer and poorer areas, and particularly, by segementing them into ‘good, deserving, comfortable’ and ‘bad, undeserving, poor’, and lastly by redefining what counts as ‘healthcare’… and providing ‘personalised’ offerings rather than universal, comprehensive ones.

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