Integration of healthcare and social care

The direction the NHS is now taking is evidence that some aspects of NHS performance arise from fundamental design flaws.

The mistake was likely made in 1948 to separate healthcare and social care. Today, as care processes shift into the community and the early forces of consumerisation in healthcare emerge, the underlying separation logic is unworkable.

Unfortunately, tax funded healthcare and cost-shared social care (coupled with split jurisdictional authority) have proved to be an administrative and financing nightmare, but more importantly a complex disconnected experience for patients. While Beveridge had a good idea, its execution has proved to be seriously flawed (it was even based on the unrealistic promise that costs would go down). In contrast, the social insurance model bundled health and social care from the beginning and we can see that it produces better care integration and outcomes. Indeed, countries with direct access to specialists appear to have better oncology and cardiovascular outcomes. There may even be evidence that gatekeeping may be causing access problems and delayed diagnosis (up to 1 year for ovarian cancer, and 2 years for neurological disorders, plus more….); proposed changes here are upsetting the BMA which opposes direct patient referral for oncology testing. One wonders what they fear that other countries don’t.

Patients and users of the NHS have no ‘skin the game’ because they lack the ability to exercise choice directly to influence quality. Proxy measures are used instead to achieve this and draw on the standard NHS ontology of committees and panels and senates and similar decision processes. Any student of such systems would know that such proceses are invariably excuses for inaction and may simply act to protect vested professional interest groups through those who sit on them.

The Greater Manchester approach is in the spirit of service integration and could lead to better quality and care, but I fear it will simply replicate the complex administrative and bureaucratic overhang that bedevils the NHS itself. In the end, it may only be redistributing resources without real service delivery innovation. Of course, if they were to replicate the Swedish approach, then perhaps there might be light at the end of the tunnel, but the funding model is wrong for that.  Simply lumping things together requires the creation of coordination systems, which will, in the end, direct managerial attention to the performance of the coordination system, and not on quality, service delivery and patient care. Keep in mind that only the patient has direct experience of the care pathway, and where it fails to integrate.

However, I have no problem with decentralising and localising services and doubt the word “National” also meant uniform services at the lowest common standard; such thinking has led to mediocre service quality, unacceptable waiting, delay and political confusion. Excellence should be allowed to flourish as evidence of how good care can be; unfortunately, localised excellence is often rubbished and characterised as post-code lotteries and multi-tierism, and ends up being used as political hay to undermine innovation.

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