A lot of hope is being pinned on integrated care systems, but when it comes to joining up health and care systems and putting the underpinning IT in place, cultural, structural and funding challenges remain
Highland Marketing's advisory board welcomed Jane Brightman, social care lead at Institute of Health and Social Care Management, to discuss the sector and its technology needs. A lot of hope is being pinned on integrated care systems, but when it comes to joining up health and care systems and putting the underpinning IT in place, cultural, structural and funding challenges remain.
The COVID-19 pandemic has shone an unaccustomed light on social care. This has illuminated the commitment of many of those working in the sector and its importance to adults with disabilities, older people, and their families.
More harshly, it has highlighted some of its problems, including the difficulty that many people face in getting the care they need, shortages of funding, staff and technology, and the precarious position of too many care homes.
Ahead of his most recent Budget, think-tanks urged chancellor Rishi Sunak to use the limelight to announce a long-term funding plan for social care. But, in the event, he announced more stop-gap funding, while promising, again, that the sector would see its much-delayed green paper by the end of the year (analysis).
Jane Brightman, who has just been appointed to lead the Institute of Health and Social Care Management’s social care activity (interview), told Highland Marketing's advisory board that this needed to happen. "I want the social care to have a long-term funding settlement and a ten-year plan like the NHS Plan," she said.
How integrated will integrated care systems be?
For the moment, social care must carry on; and hope that the arrival of integrated care systems will make a difference. The recent white paper, Integration and Innovation, says they need to join-up both health services and health and social care which is run by councils, rationed by need, and means-tested.
However, while Integration and Innovation spends a lot of time discussing one aspect of ICSs - the NHS body that will be responsible for the shift to population health management and commissioning from provider collaboratives - it spends much less on the other - the health and social care partnership that will draw up an ‘overarching plan’ for public health, health, and social care.
NHS organizations and local authorities will be expected to 'take note' of the plan in carrying out their activities; but this isn't a particularly strong requirement. So, as board member and former ICS chief information officer Cindy Fedell pointed out: "ICSs are an opportunity, but they are very NHS heavy."
Funding flows (and blockages)
Then, there's the money. Integration and Innovation makes some provision for strengthening the Better Care Fund and enabling the NHS and local government to pool budgets for joined-up care initiatives.
But, as advisory board chair and Salisbury’s previous mayor Jeremy Nettle pointed out, on the local government side there isn’t much cash around; and councillors may be reluctant to see any money that is available vanish into a system with no democratic accountability that is not at the forefront of voters’ minds.
"In Wiltshire, social care is our biggest expenditure, but we have 3,000 miles of roads and it is roads that people complain about," he said. "Local authorities have been promised some extra funding for social care this year, but it hasn’t materialized. So, people are talking about pooling funds but there may not be funds to pool."
When it comes to care homes, Brightman said the Care Quality Commission had determined that just 70 of the 18,000 providers were big enough to be a problem if they failed, while most of the rest are so small they will find it hard to contribute much to the integrated care agenda and the IT required to make it work.
Sitting behind all this, there is also that fundamental challenge that while the NHS component of care will be tax-funded, any social care component should be charged back to the individual. Which just adds a whole new layer of complexity to integrated care discussions.
One NHS and social care system?
Imaging expert Rizwan Malik said it was a shame that, for historical and political reasons, health and social care had ended up on separate tracks. "It just causes huge frustration," he said. Mark Venables, chief executive of Highland Marketing, asked the board whether one solution would be for the NHS to take over social care.
Brightman said the idea has been floated in the past, but it would be "a huge job". Labour has proposed creating a national social care service to run alongside the NHS, to provide scale and consistency. But recent governments have shown little interest in the idea.
Entrepreneur Ravi Kumar suggested some of the benefits of a national service might be delivered by creating a "social care brand" for the sector. But Brightman pointed out this had been tried.
Health and social care secretary Matt Hancock backed exactly this initiative when he wore a care lapel pin instead of an NHS pin to a Covid-19 press conference; and was promptly accused of ‘gesture politics’ and ridiculed for having nothing more practical to offer the sector (Independent news story).
Downstream action, upstream savings
In practice, it is pragmatism that is most likely to drive integrated care. Brightman told the board: "The trick [to getting funding from the NHS] is going to be recognising that social care can do a lot to prevent hospital admissions and to support discharge."
As an example, she noted that treating a urinary tract infection in the community is much cheaper than treating it in an acute hospital, where patients can deteriorate to the point where they need new care packages and end up as a 'delayed discharge'.
However, she acknowledged, social care will need status and skills to secure this kind of investment; and deliver on it. This is one of the reasons that the Institute of Healthcare Management rebranded to include social care earlier this year.
The IHSCM is now looking to provide a ‘home’ and a voice for social care leaders and managers and, perhaps, to provide certified training for them (the IHSCM is exploring a partnership with a university that may have a suitable degree programme).
The issue of certification struck a chord with Andy Kinnear who, as an NHS chief information officer, tried to drive forward professionalism in informatics by helping to create FedIP, a membership and registration body. "NHSX is describing 2021 as the year of health and social care professionalism, and it is pushing this agenda hard," he said.
"So having the IHSCM respond to that will fit with a story that is already playing out in other places. Because we do need to get together, as health and care professionals, to push the agenda forward."
A sector that needs to be more digitally mature
When it comes to technology, the social care sector has a long way to go. In councils, social care is supported by a handful of small IT suppliers with care records that have been hard to integrate with NHS systems, even in big, national initiatives such as Child Protection - Information Sharing.
The CQC has drawn up a 'what good looks like' for digital records in the sector and has similar guidance for care homes. However, last summer, a survey discovered that a fifth of care homes had no wi-fi and that fewer than half of those that did had wi-fi in both communal areas and bedrooms.
During the pandemic, NHSX and NHS Digital worked with leading telecoms companies to address this and make sure care providers could run remote GP consultations, order prescriptions electronically, and enable residents to communicate with family and friends (Care Home Management story).
The digital agencies also gave care homes NHS mail addresses, which Brightman said had made a huge difference. "I have heard people say that, because they are emailing from an NHS address, clinicians take them much more seriously," she said. "It's a great example of why the sector needs to be more digitally mature."
She added that her priority now is to "help providers understand data and security" and to get them through the Data Security and Protection Toolkit, or DSPT, which, before Covid, was required to get an NHSmail account, and is still required for "the holy grail - shared care records."
Small steps, big challenges
The advisory board discussed how the structural and funding challenges facing ICSs that want to progress integrated care initiatives are likely to make themselves felt when it comes to deploying the technology needed to make them work.
Nicola Haywood-Alexander, who took up a post as chief information officer of NHS Lincolnshire six months ago, said she would like to integrate the IT teams working on different health and social care systems and fund enhancements to their software.
But the local authority and the ICS have made different outsourcing decisions, and it’s hard to secure money unless it can be banked for specific projects. "I'd really like to do more, because there is so much we need to do," she said. "We need fibre, and satellite broadband, because sometimes on my patch I can’t get 3G or 4G, never mind 5G.
"We need single sign-on so people aren’t having to log-in to so many systems. I want to roll out workflow and productivity tools. I know the argument is that [social care] should help to fund them, but if they can’t that doesn’t help us."
In the end, it’s down to people
Shared care records illustrate the challenge. ICSs will need shared care records to support teams working on different systems, generate data for population health management, and plug in digital patient services.
They have been told to have a 'basic' record in place by September; but it doesn’t follow that social care will be involved in that basic record and there is already evidence that in many areas it won't be. James Norman, healthcare CIO at Dell Technologies and previous CIO at a large NHS trust, said national IT funds should be directed to ICSs to sort this out.
"I agree about raising the profile of social care and introducing standards, but at the end of the day we need to get money out to the service and into joint working," he said.
However, Kinnear, who also has considerable experience of driving shared care records from working on Connecting Care in Bristol, argued that it’s mutual respect and goodwill not white papers, structures and funding rounds that will sort things out on the ground.
"In the end, this is about people and people working together to do things for patients and users who are not bothered about whether it is the NHS or social care or someone else entirely who is doing the job," he said. "It is down to people in the health and care community solving things for the community."