Unlocking the integration challenge

Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.

Jeremy Hunt has become the latest in a long line of ministers to announce ambitious plans for integrating health and social care. Why have decades of such initiatives always failed in the past, and could anything be different this time?

Integration is seen as a challenge for organisations – knitting together the processes and systems of two bureaucracies. The health charity National Voices and national partnership ‘Think Local, Act Personal’ reframed the integration challenge as being to integrate care around the ‘whole person’.

For public services to achieve that goal, they need to be prepared to rethink not just their processes, but their purpose. Most services aim to fix only one kind of health or support need, but even being able to see and respond to multiple needs would not be to see the whole person, as we are all more than the sum of our needs or health conditions. A truly whole-person approach would also recognise people’s capacity – including the capacity they may have had until a crisis brought them into hospital a short time previously, and the capacity they might regain with the right support.

For most of us, a big part of our capacity and resilience lies in our relationships with partners, family and friends, so services need to be able to fit around that vital informal support.

Time for new ideas

From a traditional service management perspective, that sounds hopelessly messy, complex and time-consuming, which is why we need to replace traditional models of service design and management.

The most effective packages of long-term support are always co-designed with the people who use them and their families, as is being demonstrated by the rapidly growing number of people using personal health budgets and other forms of integrated personalised commissioning approaches that put people in charge. To open up this opportunity to everyone, we need to develop planning and brokerage support that builds on two decades of such work in the social care sector, which now has over 100,000 direct payment holders.

These are radical solutions, but every health and care service can do more to integrate its support with people’s lives and build their capacity and resilience.

Contact with a succession of strangers is never conducive to building confidence, self-care or independence – services need to replace money spent on endless layers of management with careful recruitment of people capable of taking on more autonomous roles, and ensuring those roles include time to form real relationships. The Dutch Buurtzorg home support model supports 70,000 people with dementia and other needs, but has a central team of less than 50, through building and empowering self-organising nurse-led teams.

Shared success stories

Closer to home, the UK now has 10,000 self-employed Shared Lives carers, all carefully approved following rigorous recruitment and training by one of the UK’s 150 regulated local schemes that the Care Quality Commission rates as better and safer than all other forms of regulated care.

14,000 adults have either moved in with a Shared Lives carer they have chosen and who has chosen to work with them, or visit their Shared Lives carer regularly for short breaks or day support. Harold, who has dementia, has overnight stays with Karen, in what feels like a family visit, in contrast to the overnight care home stays that Harold’s daughter Lynne had been offered previously as breaks, and which she and Harold found too disruptive and stressful to use.

Graham’s complex history of mental ill health, substance misuse and homelessness, combined with his mild learning disability, has for decades challenged traditional support services, often offered along narrow condition label lines. He now lives with Shared Lives carer Doreen, who was matched with Graham because they both love gardens and gardening. Graham lives with Doreen and her husband in a house that, after several years together, now feels like the family home and secure base he was always lacking. Matching is at the heart of Shared Lives – participants get to know each other before deciding whether a match will be right for them.

NHS England has invested £1.75 million in bringing Shared Lives from social care into integrated health care. Seven CCGs are using Shared Lives to get people out of hospital, such as those recovering from stroke or brain injury, particularly where their additional social or housing needs might have challenged traditional community-based support.

It won’t just happen

The health-giving effect of living in an ordinary family home rather than a service is easy to see. Nearly everyone using Shared Lives reports making friends, for instance, and most talk about learning or re-learning independent living skills and feeling valued by their Shared Lives household.

NHS professionals and managers understand that, but we have learned that you cannot simply place a community-based model like Shared Lives into a medicalised system and expect it to be valued and used. Local leaders have to be willing to develop new care and referral pathways and to ‘sell’ the new approach to an often stressed workforce.

If we reframe the integration challenge as being for every kind of long-term health or care support to integrate itself with people’s lives, we will be able to unlock the compassion, creativity and desire for independence that we all have, but which is too often ignored when people are placed in the role of patient. That would be a genuinely new take on integration, which might just have a chance of success. 

Alex Fox OBE is chief executive of Shared Lives Plus.

Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.