Lessons from the COVID emergency
Integrating services now looks even more important – but may be just as far away
Those of us who have been involved in developing integrated services either within the NHS or between it and other services, have always argued that this goes beyond a technical argument for change. It involves some very important moral principles that lie at the heart of health and social care. The price of continuing with existing fragmented services is paid every day by the millions of people with co-morbidities who experience falling through the many gaps between the services.
Yet despite the weight of this moral case, in 2020, in terms of practice there is still much more fragmented than integrated practice.
This failure to change practice does not come from any lack of policy drive. For more than a decade there has been a consistent policy in favour of greater integration both within the NHS and in its relationship with other services. However, improvement in integrated practice has been – even on a good day - very patchy.
In those few places where integrated practice was already happening this Covid crisis has been a test of integration. The BBC news for the 6th May ran the story of how in East Kent a “hospital in the home” scheme was looking after frail older people in their own homes. The BBC, quite rightly, described this integration between primary and secondary care as ‘rare’.
Despite all the policy initiatives, most of the NHS and social care services that were hit by the Covid crisis were still largely unintegrated and fragmented.
And yet in practice we have all been thrilled by our experience of that fragmentation. Who of us haven’t, at some stage in the last few weeks, considered the possibility that we might be, in the heavy end of an acute hospital, in one of those ICU beds? All of us have marvelled at the courage and hard slog of the people working in hospitals. They were the NHS. Their successful planning to increase the availability of NHS resources by clearing away all other priorities had clearly worked
So over the last few weeks the public image of the NHS has – if it were possible - become even more hospital-centric than before. Most of the people we thought about when we were clapping were those who took people to hospital and dealt with the emergency - in hospital. We have thrilled to the images of heroines and heroes, in their PPE, gathered around acute beds.
Very separate from that, and a few more weeks into the crisis, the public now have a greater understanding of social care and what takes place in residential care homes (and to a lesser extent in domiciliary care) . The frightening rise in the number of residents dying of Covid-19 has pushed the story to the top of the news agenda. Public sympathy for residents and staff and knowledge of their plight has grown considerably.
In the public mind there are two separate tragedies unfolding. Deaths in hospital and deaths in care homes.
Given that one of the main aims of integration is to bring these two services together their apparent separation in the public consciousness suggests that this aim remains unfulfilled.
As Vic Rayner, Executive Director of the National Care Forum, was reported as saying recently,
“Health and social care is supposed to be an integrated partnership, and it has not felt that way. Let’s make sure, whatever has happened, that we’ve learned and move on at pace. The depressing thing is that it doesn’t feel like we’ve managed to get the right support at scale.”
This lack of genuine partnership between the two sectors has had tragic consequences. Reuters carried out a large-scale investigation into the relationship between English social care and hospitals and found that there was indeed a relationship - but one of subservience by social care to hospitals - not a partnership.
At the start of their planning for dealing with the crisis, hospitals needed to clear as many beds as possible. Thousands of older people in hospital were discharged into care homes. This looked to be a very necessary part of of the process.
But having discharged these vulnerable people it seems that the NHS continued to look inward to the hospitals and failed to look outward and take some responsibility for their recently discharged (and perhaps infected) patients.
Policies that were designed to prevent hospitals from being overwhelmed by the virus pushed a much greater medical burden onto care homes. After this mass discharge it was the hospitals that were given priority by the government. For many weeks, as the death toll in care homes rose, care homes struggled to get the access to tests and protective equipment that hospitals had. (Reuters report)
Unfortunately this failure of the NHS to properly partner with social care played a role in leaving the latter bereft of clinical assistance – as well as tests and PPE. To save the lives of all of the public they serve, the NHS must learn to partner with organisations that have such a vital role.
And what of the future?
Many parts of the NHS acute sector are now, quite rightly, planning for the next phase of the recovery. System leaders are making the case to both the NHS and the public that the NHS decision-making process needs to operate - as a system - rather than as a set of individual trusts, when planning for the future.
The shorthand for this is that NHS planning for the future should be by the system by default. By this they mean that individual trusts should not be planning the recovery programme for the NHS - it needs to be planned at a system (usually an Integrated Care System) level. This is an important debate – but one that is internal to the NHS.
System by default means the top of the NHS talking to itself as if it is the whole system.
Which it isn’t.
The real system, in any locality, involves a very wide range of different organisations. Some of which are within the NHS but most of which are not. If you want to plan for a system you need a set of relationships which go way beyond the blue NHS lozenge.
We have a recent direct experience of what happens if the NHS fails to genuinely and equally partner with social care. This should not be repeated.
Just last week the NHS Confederation published their analysis: STPs - one year to go emphasising the point – as an NHS organisation - that system by default should not be the way forward. What we need is system and partnership by default.
That change in breadth recognises that, if the NHS wants to save as many lives as possible, it needs to be much humbler about how it works with others – especially local government.
The Covid crisis has taught us that when the NHS treats social care as if it is in some way outside of the system, very bad consequences will ensue.
Planning an NHS future in which this remains the case is likely to result in something even worse.
A second peak, or a second pandemic, will need real integration to deal with it.
This is the fifth instalment of Professor Paul Corrigan’s blog series on Lessons from the COVID Emergency. The full series can be viewed here.