Health and Social Care Integration – What’s the point? Clare Hammond explores the early evidence on the impact of health and social integration

Health and Social Care integration has been in the spotlight in both England and Scotland with promises of large financial savings coming from both countries. But can integration really be the silver bullet for these financially stretched services?

The Scottish Government estimated a potential annual savings of between £138 million to £157 million from the integration of Health and Social Care. This represents less than 2% of the more than £8 billion of spend integrated bodies are responsible for. When compared with the expected increase in demand of between 18 and 29% between 2010 and 2030 it is hard to see integration as the saviour of financial woes.

A core element of integration in England is the Better Care Fund which was estimated to save £511 million in its first year, a little under 10% of the pooled budget of £5.3 billion. Interestingly, the NHS Sustainability and Transformation Fund for 2016/17 had £1.8 billion of its £2.1 billion rediverted from integration to fund NHS deficits, indicating the scale of the financial situation.

So, it seems unrealistic to expect health and social care to plug the growing gap between demand and public budgets. But how is integration going in achieving the savings that are expected?

The primary assumption for integration related savings is that a more preventative and social care focused approach can steer people away from the more expensive emergency hospital-based care.

The National Audit Office (NAO) concluded that integration in England has “yet to show that integration leads to better outcomes for patients”. NHS England had hoped to reduce hospital activity growth from 2.9% to 1.3% (by 2020/2021), however both the number of admissions and delayed discharge days increased in 2015/16 at a total extra cost of £457 million. Audit Scotland are due to report on the progress in Scotland in November of this year.

Of course, you can’t know what would have occurred without a counterfactual. The NAO themselves acknowledge that there is a lack of comparable data across different care settings to place evaluation findings into context.  So, what does the evidence have to say about integration’s ability to reduce hospital admissions?

A University of Oxford study published in 2017 concluded that, while the policy discourse around Health and Social Care has pushed the approach as a solution for reducing emergency admissions, the evidence available tells a very different story. According to them, there is a mixed view on the success of a number of integrated care programmes that have been evaluated so far. Of 13 reviews conducted, only three had a significant impact on the number of hospitalisations that occurred. This review included studies on Case Management systems (a common component of health and social care integrated models) found that this approach did not have an impact on hospital admissions.

The Kings Fund has reported on a range of examples of integration at the coal face – where integration of services occurs rather than the integration of the institutions that sit behind them. One example described is in east Kent where professionals are working together across five community hubs coordinating the care individuals identified as high risk of hospitalisation. These community hubs include teams of “GPs, community nurses, social care workers, mental health professionals, pharmacists, health and social care co-ordinators and others”. They conclude that early findings suggest “that these changes have led to year-on-year reductions in emergency admissions to hospitals”.

So why is the evidence available so mixed? Well, perhaps it is as the Barker Commission concluded in 2014 of integration in England. “Moving to a single budget with a single commissioner is not a sufficient condition to tackle the myriad problems of integration that face health and social care. But we believe it is a necessary one.” Or as Scottish Government said “[s]tructural integration brings few benefits unless accompanied by many other changes”.

There may also be a problem with the focus on structural change rather than on the behavioural and relationships changes that are needed to drive real transformation.  Research by the King’s Fund identified that there was “a strong recognition that the relational and behavioural aspects of transformation deserve as much, if not more, attention than technical and structural aspects.” So integration bodies may be looking in the wrong place and not paying enough attention to how staff behave and work together on the ground…

Is it too soon to tell? While Health and Social Care Integration has been discussed for more than a decade, large scale action is still relatively new. In addition, integration is occurring in already financially strained and very complex environments. It is hard to isolate the various strands in this complexity to understand what has worked, what hasn’t, and why.

Indeed, a frequently quoted example of ‘best practice’ is Greater Manchester who are operating multi-disciplinary neighbourhood teams, intensive support targeted at those considered high risk, and driving the use of community and primary health care settings to reduce hospital use. But when you explore what makes Manchester work so well it appears to boil down to two factors:

• Their long established public-sector partnership that crosses typical service boundaries.
• Their ability to access additional funding for integration activities from the Sustainability and Transformation Plans Fund that reduces the choice between either funding rising financial pressures or integration initiatives.

Clare Hammond is an Associate Director at Rocket Science specialising in health and social care including evaluation, strategy and organisational development, cost modelling and cost benefit analysis.You can check out her profile here.

This blog is part of a wider series on Health and Social Care Integration. Other blogs in this series can be found here

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