Forget integration: we need to disintegrate our public services
How can we make sure integrated care systems work for local people? Alex Fox argues we need to avoid just integrating bureaucracies, but take the opportunity to put patients’ needs first.
Every few months I find myself in a debate about integration.
This has heated up in the last few months, with discussions about social care reform as well as the latest NHS reforms aimed at creating Integrated Care Systems (ICSs).
But as long-standing health and care watchers like Richard Humphries have pointed out, these discussions have been happening for as long as there have been separate health and care systems, with plans to integrate the two appearing every few years – dozens and dozens of them in 70 years – but none of them working.
I believe this is because we always start from the wrong question.
We look at complex NHS systems and at bureaucratic social care systems and ask: How can we join these bureaucracies up better?
As ever, it’s worth thinking about what it would look like to take a strengths-based or asset-based approach to this challenge. This would mean starting with the question:
- ‘What does a good life look like for people who use or might need health or care services?’
- And then, ‘What role do services have in enabling those people to live safely and well at home?’
The answers to those questions need to come from people themselves – particularly disabled people and older people, and their families.
They need to be conversations which include everyone – the people who make most use of health and care services now, but also the groups and communities who are most at risk of being excluded from or poorly served by those services.
The role of leaders is to do two things:
- Set a new shared goal for our dis-integrated public services. In my book, I suggest a single government department for community services bringing at least health, care, housing and local government services together, and a single goal of creating wellbeing and resilience (which is the capacity to maintain wellbeing through challenge and crises).
- Share power through insisting on co-production and resourcing the citizen-led organisations which are needed to coproduce with everyone.
The latest ICS guidance nods in this direction, but is heavier on operating systems than goals, and light, for a report on integration, on the role of councils and voluntary organisations, whose participation as local leaders is recommended but optional.
3 tests of how intergration works for local people
How would we know integration was really working for local people? I can think of three useful tests for integration. I’d be interested in what you think of them.
1. Can the system work with households as well as individuals?
This tests whether services for people with different needs (and often different ages, such as the disabled child and their parents who are finding it challenging to care for them) can organise themselves around the complexity of their lives, with them in charge of how resources are used. Or do their lives look hopelessly messy to those with power?
2. Does integration reduce inequalities?
If it doesn’t, then some services may be integrating with each other, but they are not integrating with all of our communities, and community organisations.
3. Can I own and share my own information?
This is a process-y point, but it’s a good sign of whether we are aiming to help organisations integrate their existing information systems, or if we are trying to help individuals and families take charge of their own information, and share it with the services that are valuable to them.
Having to give the same information over and over is perhaps the most common complaint about dis-integrated systems. It’s not just inconvenient – that information is sensitive, personal or can be deeply painful – so repeating it shows that our dignity is not at the heart of a service’s thinking and actions.
Scaling up innovation by scaling down bureaucracy
So real integration will be both simpler (not having to make sense of existing labyrinthine bureaucracies) and harder (services accepting new goals and less power).
We can replace systems which spend lots of time and money assessing people, but often don’t have a service, let alone the right kind of support, at the end of it, with simpler and more human approaches like Local Area Coordination, which put the rights kinds of help in the right places.
The really hard bit of scaling up innovation is scaling down what we do now. Building new integrated systems means recognising that what is needed for some monolithic bureaucracies is, in fact, disintegration.
Alex is CEO of Shared Lives Plus, the UK network for Shared Lives and Homeshare.
Alex chairs the national Building Community Capacity network for the Think Local, Act Personal partnership, of which he is Vice Chair.
He sits on the NHS Assembly, co-chaired the Covid social care taskforce’s advisory group on learning disability & autism.Join our mailing list