British Geriatrics Society

Integrating health and social commissioning

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Care for older people as a whole system.

In the UK systems for providing and commissioning health and social care for older people are based on historical priorities and objectives. Since 1948, health funding and social care funding have followed different streams through different organisations (for instance in England healthcare is funded via the NHS and social care via Local Authorities).  The system is also designed to ensure that care provided equates to assessed need at a point in time, often with no consideration of the potential for rehabilitation.  The system is designed to redress the imbalance previously in favour of secondary care, avoid hospital admission and reduce length of hospital stay.  With these priorities, but no rehabilitation people can be quickly channelled into expensive alternatives.

Older people follow various health and social care interventional pathways through the system as pressures such as frailty, illness and insufficient social support tell and their dependency level increases.  Often an unplanned admission to hospital moves the level of dependency from one quantum to the next.  Hospital based rehabilitation services in wards and day hospitals are on the decline, while recently developed alternatives such as intermediate care do not always involve a geriatrician, comprehensive assessment or rehabilitation, and vary tremendously from place to place. Mechanisms to reverse dependency appear endangered.

With increasing dependency come increasing social care costs that may be invisible to health care providers.  Health care interventions, on the other hand, may be completely inaccessible to social care providers.  For example, according to the National Audit Office, the costs of stroke to the social care budget are 40% higher than healthcare, while informal personal and family care costs are even higher still.

Northern Ireland has for many years had a legally integrated framework for health and social care.  Historically, this has not led to practical integration at commissioning or local level as the funding streams have tended to remain distinct, with the larger Trusts being exclusively based around either acute hospitals or community services.  Recent major organisational change is increasing integration across the health and social care trusts at the level of delivery, with common budgets for health care, domiciliary care and care homes.  However, the balance of commissioning between the single regional board and the local health and social care groups is unclear, while primary care commissioning has not been introduced.

The integrated care team I work with exists entirely within social care and meets every week.  Social workers and care coordinators bid for money because their client needs more looking after.  These professional staff have not previously had easy access to health systems, while their clients’ increasing levels of dependency have not yet reached the crisis point which would cause a referral to emergency services.  My involvement has led to earlier assessment, treatment and rehabilitation which is often enough to avoid, prevent or delay increasing dependency.

Integrated commissioning across the whole system could prevent avoidable dependency and avoid a premature commitment to high cost long-term packages, leading to better individual outcomes and less cost.  But there are potential pitfalls.  Integrated commissioning brings the risk that health and social care will be fighting for a slice of the same cake; GPs have had little if any involvement in these discussions; and the development of community services may lead to an accelerated decline in assessment and rehabilitation facilities unless this is addressed on a system wide basis.

There are obstacles to be overcome.  There’s little evidence base behind integrated health and social care commissioning.  Although there are a number of successful local initiatives, not a lot is happening at the whole system level.  Health and social care information systems aren’t linked.

To many, integrated commissioning seems a strange system – but that doesn’t mean it’s not worth doing and my experience is that its biggest champions are social workers and their clients.

Ken Fullerton