National and local government officials from Finland recently visited the Nuffield Trust to listen to Integrated Care Pioneers, academics, and NHS England officials describe the challenges that the Finns might face as they begin to integrate health and social care services.
Finland is one of the top five fastest ageing countries in Europe, and offers universal coverage for health and social care services. It is one of the most devolved care systems in Europe, resulting in large variation in services and access across the 200 or so municipalities. Municipalities have recently begun merging at a rapid rate. However their budgets and accountability mechanisms have not, in all cases. The current situation is not a strong starting point for joint working.
The topic of integration is therefore of particular interest to the Finns, and the Nuffield Trust asked our visitors to share with us their take away messages from our conversations. Many of their messages are ingrained in English discourse now, and are almost taken for granted, but it was helpful to be reminded of the points that can get lost in the efforts to bring services together. My reflections on their messages are below.
1. Engagement throughout is vital
One of the key messages that resonated with our visitors was the need to build relationships and distribute leadership from the outset of planning. Reflecting on their own future, the Finns worried about the perceived lack of trust between health and social care professionals, which to date has been driven by a custom of developing plans in silos and revealing them upon implementation.
Local leaders warned that this behavior had also been seen in England. Secondary care providers were not around the table when plans were made for the Better Care Fund, which prevented their buy-in and increased their fears about the shift of care to the community.
The Finns also commended the involvement of National Voices, which crafted a national narrative for coordinated person-centred care. They saw the ‘I’ statements as helpful in moving discussions away from health-dominated language, an obstructive issue which the Finns said that they endlessly discuss. The locally developed patient vignettes, likeTorquay’s Mrs Smith or East London’s Govinda (see the video below), were also seen as useful tools to illustrate to the public the consequences of fragmentation and benefits of integration.
2. Use both bottom-up and top-down approaches
Some of the English participants suggested that implementation of integrated care would be most successful in areas where local health and social care leaders and staff had a shared vision. They referenced South Devon and Torbay as an illustrative example of how a shared vision had led to an investment of funds to create a new joint health and care trust. The autonomy that had been used by the local area to develop the plan also hit home for the Finns, as many of their reforms are driven by national-level legislative changes – leaving the local areas feeling unable to innovate. Tellingly, even national officials enthused about the potential for bottom-up change, encouraging peers to “never ask the ministry for permission, we are obliged to say no”.
After lengthy discussion about the merits of local innovation, English Pioneers advised that national initiatives, like the Better Care Fund (BCF), also had their place. In England the BCF had been extremely helpful in raising awareness of the importance of (and national commitment to) integration, especially in the acute sector. Yet the Pioneers also warned that national initiatives focused solely on shifting resources can feel “transactional instead of transformational”, and that mandatory shifts of resources can also change local power dynamics where partnerships have already been established.
Recently a reform in Finland that would have brought together local authorities into five regions (to aggregate smaller local authorities) was deferred to the next Parliament, which means that will not be debated again until 2017. Delays mean that local levels have an ideal window of opportunity to try small-scale change.
3. Data linking and use is a universal challenge that needs to be overcome
By the end of the meeting we were discussing how the Finns could take advantage of this new window of opportunity. The Finns, keen on small-scale implementation and pilots, were particularly interested the development of risk stratification models. These models could help them to target people with specific risk factors, ensuring that newly integrated services initially serve people with the most complex needs.
One of the challenges they identified with taking next steps was that despite being the self-proclaimed 'land of registries’, national legislation currently obstructs many local level secondary analyses of registry data, meaning that linking health and social care data for risk stratification may not be possible. Fortunately for municipalities, a commitment was made on the spot by national officials to prioritise legislative changes to accommodate the secondary uses of data.
Having the Finns here to reflect on English progress made many of the pioneers and early adopters rightly proud of the progress they are making. For our part, we hope we made it clear to our Finnish guests that progress on integration takes a long time – and that working in integrated ways is going to be especially difficult in fragmented structures.
Kumpunen S (2015) ‘How can England’s experience of integrated care help Finland?’. Nuffield Trust comment, 9 July 2015. https://www.nuffieldtrust.org.uk/news-item/how-can-england-s-experience-of-integrated-care-help-finland