gerald wistow visiting professor in social policy. lse adass/bgs conference 2 nd july 2012 learning...
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GERALD WISTOWVISITING PROFESSOR IN SOCIAL POLICY. LSE
ADASS/BGS CONFERENCE
2ND JULY 2012
Learning from the learning: what works? an update from the latest research on commissioning
Latest Research
National Survey of Social Care Commissioning, Fernandez et al, PSSRU, LSE.
Joint Commissioning in Health and Social Care: An Exploration of Processes, Services and Outcomes, Dickinson et al, HSMC.
National Evaluation of the Department of Health’s Integrated Care Pilots, Final Report: RAND Europe, Ernst & Young
Integrated care: a story of hard won success, Vize, BMJ.
Social Care, Fourteenth Report of Session 2010–12, House of Commons Health Committee.
Research Findings
‘the development of each service was usually considered in isolation, and it could not be said that there was an overall plan for the development of services for the elderly in any of the authorities studied’
‘when asked how the substitutability of related services had influenced plans for his authority, he added: ‘that sounds too logical, and in fact was not how it happened’
Research Findings
the more significant bar to co-operation was the division of responsibility without a clear-cut division of function. Too often this led to failure to develop a service because each side could argue the other should do it’
The local authority associations …….warned that if they were not able to meet the extra expenditure needed to expand their services, the Minister’s hospital plan would be imperilled
My Source
Greta Sumner and Randall Smith Planning Local Authority Services for the Elderly 1969
Study of planning in 24 authorities in response to joint planning circular of January 1962
Circular described hospital development as complementary to the expected development of the
services for prevention and care in the community and a continued expansion of those services has been assumed in the assessment of hospital provision to be aimed at’
Local authorities enable hospital re-configuration through integrated planning (commissioning)
Integration Today
While many people told us of excellent care, we heard alarming stories, particularly from the most vulnerable, of poor access, falling through gaps between services and being unable to understand how to navigate their way through the convoluted ‘system’. We heard from people who had experienced delays and come to harm. The universal feedback was that the current system is fragmented and all patients, regardless of their circumstances, want a more joined‐up and integrated health and social care service, planned around their needs
(Field 2012 p.9).
Integration and Quality
‘Sadly……..we have been told repeatedly that the system, as it stands, often does not deliver the integrated package of care that people (with complex problems) need. It doesn’t deliver their desired outcomes either………There are often wide gaps between services…. The often inefficient and unreliable transitions between services result in duplication, delays, missed opportunities and safety risks…………and we know the recent scandals in hospitals, home care, and care homes will not go away if we don’t change the way the system works.’
(Integration Future Forum 2012)
The traditional framework
Statutory duties to work together Coterminous boundariesCoordinating structures Joint plansFinancial incentivesPermissive powersBridges between parallel organisations rather
than integration of mainstream business processes
Seamlessly joined not woven together
Integration has not worked………
‘Despite repeated attempts to “bridge” the gap between the NHS and social care……..little by way of integration has been achieved over this 40 year period’.
Long line of initiatives to design new frameworks for integration, each beginning with recognition that the last had limited results
Some success: contribution to closing long stay hospitals and creation of islands of good practice often despite ‘the system’
Can the latest statutory framework succeed where others didn’t?
Time to Face the Facts?
Consistent weaknesses raise questions of systemic failure and fitness for purpose
Implementation deficiencies or flawed design?Both: institutions of structure, process and
culture create the spaces within which implementation is conducted with more or less skill, creativity and commitment
Those institutions, in turn, are rooted in decisions at foundation of NHS and 1974 reorganisations
Institutions of NHS and local government designed to be different and separate not similar or integrated
………we always knew it was sub optimal
Organisations primarily based on ‘Skills of professionals not needs of clients’ A place, local variety and functional coordination The service, national uniformity and functional
specialisationCoterminosity ‘an attempt to get as near as possible
to the advantages of…..unification by creating “two parallel but interacting structures” (Joseph)
A ‘miserable middle way’ (Crossman)Need outward looking ‘community governance’
(Stewart)
……….and integration has become more difficult
Unilateral redrawing of boundary between health and social care as NHS ‘withdrew’ from continuing care and concentrated on acute interventions
Intensified boundary disputes; extended means testing to growing numbers of owner occupiers; increased levels of dependency and financial pressure in social care
Social care funding gap a product of NHS cost shunting as well as unequal growth rates
Stronger hierarchy (‘targets and terror’) reinforced internal not joint agendas and made NHS even more hospital centric
…..but we need it more than ever.
Less hospital centred care and support systems with proper investment in community networks and informal care, together with shift to prevention, early intervention, wellbeing and independence
Meeting Nicholson challenge through shift in responsibilities and resources
More effective use of resources: address suboptimal balance of national spending; community budgets locally; reduced support costs
Personalised commissioning: more choice, control and joined up services
Some learning
No silver bullets but there some critical elements to the mix
No clear link between joint commissioning and better outcomes
Structure and process put before purpose and outcome
If integration is the answer, what is the question? How to secure optimal outcomes by meeting
needs holistically and ensuring that the “right” services are available at the “right” time from the “right” people, in the “right” place
Means moving resources, high and low politics, power as well as technical competence
Some learning
Multileveled commissioning for whole systems and joined up service delivery
Hierarchy normally trumps partnership: optimal balance between opposing vertical and horizontal forces
Structure and agency important: build the necessary institutions and relationships
Process of reform disrupts existing relationships and focusses attention on internal organisational concerns rather than external relationships and better outcomes for individuals and communities
Expect slow and limited progressThe omens are not good
Case for Deeper Change
Rebalancing investment, new service models and removal of fragmented service delivery needs improved integration
The conventional model of integration has failed repeatedly across five decades
We can do better but it tends to be by working across the grain of mainstream systems and processes
‘It seems perverse to attempt to build integrated service delivery on a fragmented commissioning system’
Single point for commissioning, single budget and single accountable officer necessary for deep change
How can we commission better health and social care services?
Research tells us more about what doesn’t work than what does
Integrated commissioning generally not workingIntegrated commissioning is necessary but not sufficientPerson centred as well as systems centred commissioningLocal leadership necessary but not sufficientWe can make small improvements within space
organisational settlement allows but probably not the radical changes to service structures and investments needed
Continuing tale of provider power and ineffective government
Can local leaders make central government an offer they can’t refuse as Griffiths did Thatcher
Episodic and long term care rather than health and social care
How can we commission better health and social care services?
We can make small improvements within space organisational settlement allows but probably not the radical changes to service structures and investments needed
Continuing tale of provider power and ineffective government
Can local leaders make central government an offer they can’t refuse as Griffiths did Thatcher
Episodic and long term care rather than health and social care
Thank you
gerald.wistow @btinternet.com