Integration

Integration is the buzzword of the time. We are told that the Health Bill will promote the concept and a scan of the explanatory notes show that integration is covered in four clauses: 20, 23, 59 and 62. The first two alters the National Health Service Act 2006 the other two are clauses of the Health and Social Care Bill.

Clause 20 and 23 are almost the same, the former refers to the responsibilities of the NHS Commissioning Board, the latter refers to the responsibilities of the Clinical Commissioning Groups. Both of these say that the NCB/CCG must have a view to secure health services "in an integrated way" when "it considers" that this would improve quality or reduce inequalities. Similarly it says that the NCB/CCG must have a view to secure the provision of health services is "integrated with the provision of health related services or social care services" when "it considers" that this would improve quality or reduce inequalities. Further, clause 20 says that the NCB must encourage CCGs to work with local authorities to integrate health services and integrate health and social care services.

Clause 59 makes similar statements about Monitor, saying that it "must exercise its functions with a view to enabling health care services provided for the purposes of the NHS to be provided in an integrated way". Similarly Monitor must enable the provision of healthcare services to be integrated with social care services. Clause 62 says that Monitor must "have regard to" ensuring that different providers co-operate with each other.

All of this sounds fine, except that it does not say what "integration" is. The term is not defined in the Bill, nor is it defined in the explanatory notes. It simply says that services must be integrated if it is considered that this will mean a better quality for services or if it will reduce inequalities. The "it considers" phrase is interesting because it does not mandate such actions. It does not say what this consideration is, nor what redress there is if others have a different opinion. The Bill does not define what "quality" is when it comes to integration.

Presumably this means that integration (whatever that is) can be ignored if the NCB/CCG considers (whatever that means) that quality (whatever that is) won't be improved or if inequalities won't be reduced. None of this seems to promise anything at all.

The Bill explicitly maintains the separation of the duty to provide social care (a local authority duty) and health services (and NHS duty, that will be in the gift of CCGs). The Bill explicitly imposes a duty of competition and "choice" (see clause 71) which will fragment the service. The Bill explicitly sets up a price list system called the "the national tariff" yet nowhere within this pricing system does it mention the integration of services, or ensuring that the national tariff does not prevent the integration of health services or the integration of health and social care services.

Why is this important? Well competition is the antithesis of integration, competition means that providers must compete to provide services and therefore are always working to replace, rather than work with, other providers. Different providers can co-operate (clause 62 says that they must) but if there is a single provider for all services it is far easier for the services to be provided in an integrated way. For example, a single provider will have a single mechanism for patient notes; a single provider can provide a single system for patient complaints and the resolution of those complaints; and a single provider ensures that there is just one budget. Multiple providers allows for a considerable amount of buck-passing, with providers saying that it is "not their responsibility" or that their budget "does not cover that". There is nothing in the Bill saying that there is a duty to reduce (or eliminate) this buck-passing.

The Bill says that the NCB, Monitor and CCGs all have a duty to secure provision of integrated services, but Monitor has a responsibility to prevent "anti-competitive behaviour" so that would mean that CCGs would have to find a middle ground between integration of services (to keep NCB happy) and competition (to keep Monitor happy).

In HSJ Prof Bob Hudson says: 

"In the meantime, established joint arrangements between the NHS and social care are collapsing. The implosion of PCTs has destroyed the high trust networks that have been developed with some far-sighted councils; some CCGs are already demanding to have ‘their’ community nurses returned from integrated teams; councils are withdrawing social workers from integrated mental health teams; and disputes about responsibility for funding continuing health care are escalating. Far from moving forwards, the collaboration clock is actually being turned backwards."

This is concerning and does not bode well for the prospects of a comprehensive integrated service in the future.

Basically, the Bill plays lip service to integration but does not say what it is and makes little attempt to ensure that it happens.