“Integration” is the buzzword in healthcare but many don’t really understand what it means. Mike Birtwistle draws some clarity from the confusion.
We are in the throes of party conference season. As ever, most of the interesting developments will occur on the fringe but one topic of discussion is a given – in Glasgow, Manchester and Brighton, hundreds of activists (OK, lobbyists) will earnestly discuss how wonderful the concept of integration is.
‘Few will bother to define what they mean by integration. The word is used as polite code for a range of very different and sometimes unpalatable issues’
The trouble is, few will bother to define what they mean by integration. This matters, because the word is used as polite code for a range of very different and sometimes unpalatable issues. To help people avoid unwittingly supporting things they might not actually agree with, this is my attempt at unraveling the integration code.
Meaning 1: Cuts
I am pretty sure that few, if any, proponents of integration would also advocate reductions in health or social care spending. Yet those who welcome the £3.8bn integration fund will be supporting just that. The fund amounts to a stealthy way of transferring money from inside the fence – supposedly protecting NHS expenditure – to outside, papering over the ever-widening cracks in social care budgets.
Whatever the governance mechanism, once this stealth transfer is taken into account, a small real-terms increase becomes a rather large real-terms cut. Yet such is the magical power of the ‘I’ word that even the Opposition (surely on the lookout for broken promises on NHS expenditure) initially welcomed the fund.
If funding for health is to be cut, it shouldn’t be done under the cover of integration.
Meaning 2: Anti-competition
Integration is not an antonym of competition, but it is often used that way. Plenty of integrated services are delivered in highly competitive environments but, for those opposed to competition in the NHS, the integration imperative has become a central part of the argument.
Opposition to competition in the NHS (or being fearful of its implications) is a perfectly reasonable position to take but the reason for this position should not be concern over integration. After all, there are plenty areas of healthcare where there is little or no competition, but also little or no integration.
If services not subject to competitive forces were integrated, we wouldn’t be having this discussion.
Meaning 3: Structural reform
‘Much of the debate about how to secure integration revolves around somehow forcing NHS and social care commissioners to share budgets’
Much of the debate about how to secure integration revolves around somehow forcing NHS and social care commissioners to share budgets. The argument goes that organic efforts to pool budgets or secure integration through other means are insufficient and that history needs to be given a push.
Many of the proponents of this approach were also the people who expressed fears about the negative impact of structural reform in the past. Yet, make no mistake about it, efforts to force the sharing of budgets amount to structural reform – and on a scale never seen before.
Surely one of the lessons from the Lansley reforms is that it is better to be explicit about looming structural change than it is to talk about it in code? The code is damaging because it means that organisations that should know better end up advocating things they probably don’t mean.
‘If the NHS genuinely believes the rhetoric on integration, then it should put its money where its mouth is’
It is also damaging because it avoids discussion about how to actually make real what is surely the intended goal of integration: services where people don’t fall down the cracks between organisations. If we were to scrap the code and instead have a more meaningful discussion, here would be a couple of my suggestions.
First, we need to find a way of measuring the outcome of integration. Then we need to reward its delivery. As National Voices has pointed out, the only form of integration that matters is that which occurs from a user perspective.
Patient experience surveys (no, not the friends and family test) often ask whether health professionals worked well together. We should pay providers on the basis of their results. Yes, the fault for a failure to work together might lie with more than one organisation but isn’t that the point of encouraging integration?
Second, if we value integration, we should pay for it as a process as well as an outcome. If the desired result is coordinated services, establish a tariff so people will provide exactly that. There is a cost implication to this, but if the NHS genuinely believes the rhetoric on integration, then it should put its money where its mouth is.
Much of the talk on integration is code for something else. Its use prevents meaningful discussion about how to join up services. I, for one, will be trying to avoid using the ‘I’ word.
This article was first published in the Health Service Journal. You can read it here.