Why is integration of health and social care so difficult?

 Caroline Glendenning described the necessary ingredients for service integration nearly 20 years ago. They were: Close-knit professional networks;  a mutual sense of long-term obligation; little concern about reciprocation; a high degree of mutual trust; and joint working as core business. If you take this recipe to health and social services in 2019 will many professionals recognise them as features of their work environment? Sadly, I think few will.


There is something to be learned about integration from the USA (although this sometimes provokes fears of privatisation). Leutz’s rules are particularly relevant. They are:


    1. Integration of services: You can integrate all of the services for some of the people, some of the services for all of the people, but  you can’t integrate all of the services for all of the people
    2. Integration costs before it pays
    3. Your integration is my fragmentation
    4. You cannot integrate a square peg and a round hole


  • The one who integrates calls the tune


What does it mean to say “You cannot integrate a square peg and a round hole?” We ran a series of workshops with people from different backgrounds in the NHS to try and answer this question.


We took social care as the round hole and the NHS as the square peg, and explored what made their characteristics. 


Since 2001 there have been 12 White Papers, Green Papers and other consultations about social care in England, as well as five independent reviews and commissions. Very few of the key recommendations have been implemented. Since 2010 social care budgets have been cut by 20% or more.


Care homes operate in an economy that is difficult to manage; there are 11,300+ care homes run by 5,500 providers housing  410,000 + people. The care home industry is 3 X size of NHS in terms of bedspace, and 95% of care homes are independently- owned (for-profit and not-for-profit) 


The Competition & Markets Authority  Care homes market study (2017) concluded that older people needed greater support in choosing a care home, and greater protections as residents. Local authority (LA)-funded residents are subsidised by self-payers but this is not unlikely to be sustainable without additional public funding. 


The NHS is a stalled bureaucracy, struggling to adapt to demographic change and to sustain service innovations, slow to adopt IT solutions to patient or system management, and resistant to service re-organisation.


Within the NHS resource allocation policies have had a limited effect on funding flows, and community based services have shrunk whilst acute hospitals absorb the NHS budget.


The acute sector will further extend its influence over resource allocation ( think of ‘personalised medicine’). A shift towards local authority commissioning of health services may help overcome this problem, but other mechanisms need to be explored.


The current purchaser-provider split has not been a success but to promote integration we will need to manage competing demands for resources (if only because integration costs before it pays).  Local authorities have experience of commissioning but have been weakened by austerity policies. Investment in LAs may be needed for them to take up commissioning of health services.


So, to start the integration of health and social care we will need to decentralise decision-making about service development, invest in local authority commissioning, cap acute sector spending and divert and ring-fence funds to community-based care. No pressure!


Steve Iliffe & Richard Bourne

This blog is based on a presentation given to the Health Policy & Politics Network conference, Green Templeton College, Oxford Friday 13th September 2019

Sources are available from the authors (s.iliffe@ucl.ac.uk, richardbourne@msn.com


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