Though the answer may be integration, we don’t always know what the question is.
Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:
Integration across any of primary, secondary and tertiary healthcare
Integration across health and social care (and education and housing and etc.) boundaries
Integration of resources and processes
Integration at the level of the individual.
As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.Mathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.
Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.
Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.
Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.
And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.
(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)
If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:
Integration is harder than differentiation – though there are limited tricks to make it easier
It gives a bigger picture across a wider area than a specific view of just one point in time or space
It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
Integration is a subtle, complex process that takes time and understanding to do.
Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.
We all have our favourite “I can’t believe that actually happened” stories in social care.
Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).
It would be funny if it weren’t so normal.
But we hear variations of this all the time, summarised in the line:
Of course what I do is person-centred care – it always has been
If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).
This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:
Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions
Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.
It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.
A natural question to ask is “What’s that?”, and it’s a very good question.
Before answering that, though, I think there are questions we should ask before, such as:
“What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
“What difference do each make?”
This is the third of three posts looking at each topic individually (see the introduction to this short series and the posts on ‘integrated’ and ‘personal’). It’s a very quick way into the issue of commissioning, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.
What do we mean by ‘commissioning’?
Put bluntly, the core role of commissioners has been to buy services for their populations, although it has always been more than this.
This is from Health Select Committee’s report on Commissioning in the NHS (pdf) – a report which notes (rightly) that the vast majority of the public don’t know what commissioning is despite its central importance to the running of health and social care. There are endless reports, chapters and even books on the topic of commissioning. Below, therefore, is a very brief summary of some of the key developments in commissioning relevant to health and social care.
Commissioning in the NHS began in earnest with the ‘purchaser-provider’ split of 1991 and has
been maintained since then (though in various guises – see Box 1 to the right). The “more” than buying services for populations that commissioning is has best been captured by the commissioning cycle. There are hundreds of versions of the commissioning cycle, but each is essentially a variation of the following:
As with integration, commissioning can happen at a variety of different levels. This is most obvious in health:
Commissioning in social care also emerged at the same time as the purchaser-provider split in the NHS. It took a slightly different form, however, with more emphasis put on the role of care management – where social workers were central to assessing need, arranging packages of care and managing and negotiating resources. This new approach was reflected in the Caring for People White Paper (1989).
Commissioning has come a long way since then, at least in the number of commissioners. The Barker Commission highlighted particular the problem of increasing fragmentation of commissioning responsibilities between different organisations within the NHS and local government – estimating there to be over 400 organisations with responsibility for commissioning. The main response to this has been “joint” or “integrated” commissioning across health and social care.
The development of personalisation in adult social care was a focus of attention in commissioning, especially focusing on the role of market shaping, market facilitation and market development. This was a new role for local government, best captured in the work of the National Market Development Forum (pdf).
Finally, an alternative to top-down commissioning is bottom-up commissioning, or more nicely what we might call people- or community-led commissioning. At the individual level this is essentially what Direct Payments are (and what we are seeing in the extension to Personal Health Budgets; see the post on Personal for more information on what this is and its effects). At a collective level it is best represented by the idea of co-production in commissioning or people-powered health.
Options for integrated commissioning – a very useful document that looks at what existing joint/integrated arrangements currently exist (Section 75 arrangements etc.) and what options we have for the future (King’s Fund)
People-led commissioning – both through co-production in commissioning and people-powered commissioning (Note: we don’t here include information approaches to building community capacity or community empowerment, although these are arguably varieties of commissioning.)
[It is] clear that there are few examples of robust evaluations of commissioning in the academic literature. Moreover, the grey and practitioner literature tends to focus on commissioning in single government departments, local initiatives or single services/client groups. It has been noted that the efficiency, effectiveness and efficacy of commissioning and strategic commissioning is typically taken for granted rather than demonstrated… The evidence base on the outcomes of commissioning remains under-developed and such evidence as exists is equivocal – Williams et al. (pdf)
Asking whether commissioning makes a difference is a very interesting question. One of the issues with it is knowing exactly whether what is happening in practice is actually good commissioning. Mark Britnell, who led the development of World Class Commissioning within the NHS, commented:
It might strike you as slightly odd—it did me coming into the department—that no-one had defined what good commissioning was in 20 or 30 years. (para 137) (pdf)
Having thus defined what good commissioning looked like, an assurance framework to quantify how good commissioners were showed that most commissioning wasn’t very good: in only one of ten competencies did people achieve better than half marks in their ranking:
If knowing what was happening in practice was actually commissioning was one problem, the other major issue was in understanding the difference commissioning makes is. The main issue here was the lack of a counterfactual: if commissioning is the only option, there’s nothing to compare it against.
Against this backdrop, we therefore shouldn’t be surprised to read that nearly all flavours of commissioning attempted in the NHS have not had much impact against a variety of themes, including efficiency, equity, changing patterns of service delivery, quality and partnership working.
The best of what we do have is therefore as follows:
On integrated commissioning, there is even less information. As concluded here:
Overall the research suggests that examples of fully integrated commissioning are limited, and that this approach is typically confined to a small number of service areas. It follows that research into the nature and, in particular, the effectiveness of joint commissioning is also relatively limited… The evidence that is available suggests that the nature and success of integrated commissioning arrangements varies significantly between local areas and between services.
People-led commissioning is an emerging area; as such, the literature is nowhere as well developed. There are some bits of evidence, however, most notably the findings of the People-Powered Health initiative (pdf). Other evidence is available from particular sites, such as work in the Isle of Wight done by the Health Foundation.
A natural question to ask is “What’s that?”, and it’s a very good question.
Before answering that, though, I think there are questions we should ask before, such as:
“What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
“What difference do each make?”
This is the second of three posts looking at each topic individually (see the introduction to this short series). It’s a very quick way into the issue of what we might mean by ‘personal’, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.
What do we mean by ‘personal’?
The last 15 years have seen a shift towards more responsive, personal public services. Adult social care has been at the forefront of this shift, with policy areas such as health acknowledging and adopting the difference that social care has seen as a result.
I’d suggest a ‘personal’ approach to health and social care broadly encompasses two interconnected, perhaps even indistinguishable areas: personalisation and person-centred approaches.
The landmark policy statement for personalisation was the Putting People First Concordat of 2007 (pdf). In this we see the key principles of a personalised approach: “Replacing paternalistic, reactive care of variable quality with [a] focus on prevention, early intervention, and high quality personally tailored services… [where] people have maximum choice, control and power… People who use social care services and their families will increasingly shape and commission their own services” (p.2). The Care Act (2014) has since embedded many of these principles in legislation (see also the “policy and legislation” box here (pdf) (p.4)).
The second chapter of the Five Year Forward View is explicit about preventative, person-centred, empowering approaches in health. This itself builds on Domain 2 of the NHS Outcomes Framework which focuses on enhancing the quality of life for people with long-term health conditions through personalised care and support planning. Bothe the 5YFV and Domain 2 of the NHS Outcomes Framework are why we see such a focus on person-centred approaches in the Vanguards/New Models of Care support offer, whose Chapter 4 shares what that key programme will do to empower people and communities through, for example, person-centred care and support, and services created in partnership with people and communities (pp.18-19) (pdf).
Because personalisation and person-centred approaches have been around and developed over the last 15 years in particular there is no shortage of information about them. There are, I think, four sources that provide the best introduction to personalisation and person-centred approaches:
Getting Serious About Personalisation in the NHS (pdf) – written for those who are working in health and care organisations that will need to change systems and practices to deliver personalised, integrated care and support
Think Local Act Personal’s personalised care and support planning tool – This includes a section that usefully defines what personalised care and support planning is, its origins, its values and principles, related behaviours and beliefs of professionals and what personalised care and support planning looks like in health and care settings
The Health Foundation has a subsite focused on person-centred care, with a wide range of resources exploring this vast topic. This incorporates the link to key areas of person-centred approaches such as shared decision making and self-management
What difference does ‘personal’ make?
Like integration there is no shortage of evidence regarding personalisation and person-centred approaches. Here’s the evidence that I’ve personally found most useful.
The Individual Budgets evaluation – the first significant, robust study on the difference that personalisation makes – especially through the mechanism of Direct Payments / Personal Budgets (SPRU, 2008)
A partnership of In Control and Lancaster University has published three Personalisation Outcomes Evaluation Tool (POET) survey findings. These surveys explore the difference Personal Budgets have made to people with them and their carers, as well as their experience of the process. Findings are available for 2011 (pdf), 2013 (pdf) and 2014 (pdf)
HSCIC’s annual adult social care survey includes comparisons of the experiences of people on Direct Payments or Personal Budgets compared to other forms of social care support. The latest data available is for 2013/14 (pdf) (and see, for example, Figure 2.8 on page 53 – reproduced below)
The Social Care Elf and Mental Elf have usefully summarised some key studies on the effects of personalisation and Personal Budgets for key user groups: for older people, for people with mental health problems, and for carers
Building on their surveys for adult social care, In Control and Lancaster University have also produced three POET surveys capturing the difference Personal Health Budget have made to their holders and their carers, as well as their experience of the process: 2013 (pdf), 2014 (pdf), 2015 (pdf)
A natural question to ask is “What’s that?”, and it’s a very good question.
Before answering that, though, I think there are questions we should ask before, such as:
“What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
“What difference do each make?”
This is the first of three posts looking at each topic individually (see the introduction to this short series). It’s a very quick way into the issue of integration, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.
What do we mean by ‘integration’?
It’s perhaps easier to ask the question: “Integration between what?” because there is no one type of integration. Integration could mean:
Across sectors (e.g. health and social care; health, care and education; health, care and housing etc.)
Within one sector (e.g. between mental health and physical health)
Across different levels (e.g. prevention, early intervention, primary, community, secondary and tertiary health services)
Across providers
At parts of a process (e.g. single assessment or review).
There is also a question of the extent to which integration happens. So, for example, it’s possible to link things together, co-ordinate things or fully integrate them (see page 15 here (pdf)). Finally, there’s the option of whether integration is “real” (i.e. mergers between organisations or physical assets, such as teams) or “virtual” (i.e. partnerships, alliances or other relationships between organisations).
Since integration can mean a whole host of things in practice, there are various “typologies of integration” that try and capture these. See, for example, Fulop’s typologies of integrated care (p.4) or a discussion of macro, meso and micro levels of integration (pdf). Thus, locating yourself in what type of ‘integration’ is being done is important in the first place.
We most typically associate integration in the current context within integration across health and social care. A 2011 discussion paper from the King’s Fund that covers this topic quite comprehensively is here (pdf). A 2015 article on the same from Richard Humphries is here.
What difference does integration make?
You can fall into this rabbit hole and never emerge, so significant is the literature on the difference (or otherwise) that integration makes. It literally has its own journals (note: plural).
Even so, here are a few of what I’ve found to be the most useful bits of research on the difference integration makes:
Significant and detailed report on the difference different ways of integrating (care co-ordination in networked or integrated organisations) makes from a person’s point of view (see page xxii for easy summary) (NIHR)
A natural question to ask is “What’s that?”, and it’s a very good question.
Before answering that, though, I think there are questions we should ask before, such as:
“What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
“What difference do each make?”
Over the next couple of weeks I’m therefore going to write 3 posts on each of these topics, and for each I’m going to try and answer those questions.
Each post will be a very quick way into the issue, sharing information that I’ve found useful in my own learning. None will be in any way comprehensive! Thus, if there are things you’d like to add to each post or disagree with, feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.
A Technical Annex (pdf) to go with CQC’s State of Care 2012/13 report, you say? How could I possibly resist?!
Below are some highlights from the annex looking specifically at the funding of adult social care. (These figures will be familiar to folks who pore over the HSCIC releases every quarter, but I take the view you can never get enough of info like this.)
Total and type of spend on adult social care:
Spend on adult social care has risen in cash terms – from £16.8bn in 2009/10 to £17.2bn in 2012/13, but there has been a real terms decline. Adults under 65 with a learning disability where the only major user group to see a real terms rise in expenditure from 2009/10 to 2011/12.
The following proportions were spent on the following client groups in 2011/12(figures include Supporting People monies, which was presumably found down the back of the sofa in the last year or so
53% of spend was on older people
31% on adults under 65 with learning disabilities
9% on adults under 65 with physical/sensory impairments
7% on adults under 65 with mental health problems
Direct Payments expenditure:
Expenditure on direct payments for adults increased in both cash and real terms. £360m was spend on Direct Payments in 2006/07 and reached £1.1bn in 2011/12
This is a real terms increase of 175% and is 6% of all gross adult social care spend.
Unit costs of different types of social care are fascinating. Really.
The average cost per adult supported in residential care, nursing care or intensively in their own home was £608 per person per week in 2011/12 – a 5% real terms cut
The average cost of providing day care for adults (including older people) was £213 per person per week
The cost of home care per person per week for all adults was £206.
Top-ups
This one surprised me: the overall proportion of people who indicated that they (or their family) ‘top up’ their care has increased from 38.1% in 2010/11 to 38.8% in 2012/13. This probably isn’t as much as I thought it would be.
To summarise, there’s less money in real terms, no matter what anyone else tells you.
For those folks who want extra geek points – and, frankly, who doesn’t? – it’s well worth reading CQC’s technical funding annex in conjunction with the King’s Fund’s submission (pdf) to the Health Select Committee’s Inquiry into public expenditure on health on social care. In social care, it notes:
The number of older people receiving publicly funded services has fallen by 26 per cent since 2009/10, with an equivalent reduction of 21 per cent among working age adults over the same period. Given the overriding imperative to provide care closer to home and reduce the need for residential care and hospital admissions, it is particularly worrying that the largest reduction has been in the use of community-based services such as home care (down 25 per cent) compared to nursing home care (down 4 per cent) and residential care (down 1.7 per cent).
Their numbers on the NHS are just as frightening.
So, to summarise again:
There’s less money in adult social care
There are less people getting adult social care
The number of people getting fewer services is rising quicker than the rate at which money is being taken out of the social care system
Money is being cut from services which cost less and people prefer quicker than it is being cut from services which cost more and people prefer less
The NHS is fairly buggered, or at least faces the biggest financial challenge it has ever faced.
GPs will oversee social care for vulnerable patients… Family doctors will “case manage proactively” patients with complex needs by developing and regularly reviewing personalised care plans that will cover health and social care needs.
As always, there are details to be worked out – not least of which is who actually does the care co-ordination. Nevertheless, let’s not allow details to stand in the way of some reflections:
This isn’t integration: this is health taking over social care. Goodness knows there are issues and problems in social care, but I’d suggest more learning about coordination and person-centred approaches can flow from social care to health than vice versa
If the Secretary of State really thinks this is about “fixing the long-term pressures on our A&E services, empowering hard-working doctors and improving care for those with the greatest need” then he’s (1) motivated by the wrong things at the wrong end of the system, (2) empowering the wrong people, and (3) putting last those people who should be put first.
This stuff is soggy trifle.
Update (22 November): Mithran over at Community Care does a nice summary of the findings of some research on GPs and social workers working together. The full research is here (pdf) – great study through those lovely folks at the School for Social Care Research.
It’s not efficiencies. It’s not bloated public spending. It’s disabled people not being supported to meet the most basic elements of day-to-day life – getting out of bed, making a cup of tea, or going to the supermarket.
I’ve immodestly quoted from a post I wrote over 3 year ago on the Independent Living Fund, when it was announced it was closed to new applicants. 6 months later, I wrote another post after it was officially announced ILF was to close from 2015, noting responsibility was likely to fall to those well known cash-rich organisations, local councils.
Today, a court of appeal bid to overturn the abolition of the ILF has been approved. I haven’t seen the full judgment, but it seems to cite both the Equality Act (and great work from the EHRC for intervening to this effect) and that the decision to close the Fund didn’t take account of the flavour of consultation responses.
This is good news.
It doesn’t solve the problem, though, of what to do with the Independent Living Fund in the long term.
For me, the definitive report on what to do with the Independent Living Fund was written in 2006 by Melanie Henwood and Bob Hudson. It notes the peculiar history of the ILF: set up in 1988 as a transitional arrangement, a related new fund created in 1993, the original fund closed to new applications but replaced by an extension fund, all meaning there have actually been two funds operating in parallel since 1993. The report also highlights the huge number of considerations that have to be taken into account when doing anything with the ILF, not least of which is recognising the vital support it provides to 19,000 people.
And it also notes the ILF is anomalous in the long term, and that it continues to account for a large amount of social care expenditure whilst operating to different rules and remits that are incongruent to mainstream social care. It also notes ILF can result in inequity, unaccountability, duplication, arbitrary decisions and major confusion.
As such, the report concludes the ILF should close.
I agree.
But…
In closing the ILF, there are a number of points and principles which must be observed, and that at a minimum are:
Any transition from ILF to other funded support should be slow and steady. (In the 3 years since DWP announced the closure of the ILF in 2015, I think very little activity could be detected)
The money people received through ILF should be protected, and most definitely shouldn’t be swallowed up by local authority budgets
The better parts of the ILF (such as a national, portable system) should influence the new location of the money, rather than these being lost.
The world since Henwood and Hudson wrote their report has changed, not least in the considerable cuts we are seeing in social care and the wider health and welfare reforms. But shifting the principles and support of the ILF into the main provision of social care is still the best thing to do, as long as the minimum points above are met.
The DWP’s original attempt at closing the ILF clearly didn’t do this; the motivation was instead to cut money, and the court of appeal has rightly picked them up on it.
Now, though, there is a chance to look again at this properly. Hopefully the DWP will do this, and do it:
With people from the Department of Health working on the Care Bill and the Integration Transformation Fund
With people driving the personalisation of health and social care
Most importantly, with the people who will be affected by the change.
Update: the full court of appeal judgment is here. It indeed uses the Public Sector Equality Duty as the basis of quashing the original decision.
Despite what my wife says and what my schoolteachers used to say, my natural state is not one of being a pain in the arse.
I’m at risk of seeming like this, though, when it comes to the integration in health and social care.
I say this for two reasons:
Last week, I blogged to note that integration in mental health hasn’t had the most positive effect on personalisation, and to ask how we can work to ensure the same doesn’t happen more generally
After reading the most recent announcement on the Integration Transformation Fund (see here – pdf) I’ve noticed that part of the Fund in 2015/16 will be made up of c£220m of Disabled Facilities Grant funding and £130m Carers’ Breaks funding.
We knew that the Integration Transformation Fund wasn’t going to be new money, and we knew Paul (aka integration of health and social care) needs the money. But Peter (aka disabled people in their inaccessible homes and carers) isn’t exactly rolling in it at the moment.
Just to prove my wife and schoolteachers wrong (always a strong motivation, that), let’s end on two positives:
Integration across health and social care is absolutely something to aim for, for all the reasons people highlight (including the money and the currently artificial divide between health and social care that affects people more than it affects budget lines)
Without a doubt the most successful integration will be done at the level of the individual, for example (but not only) bringing together Personal Budgets and Personal Health Budgets. As much as possible should therefore be done to enable this (but without, I’d suggest, nicking money from where there already isn’t very much!)
Mathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.
The landmark policy statement for personalisation was the 
arbitrary constant 