Last reviewed 5 September 2016

Christine Grey continues her look at health and social care integration projects with news from Wales and Northern Ireland.

Despite Northern Ireland having had the benefit of an integrated health and social care structure for many years it has been the slowest to exploit the potential benefits, so its government recently announced a renewed need to reform Northern Ireland’s systems to keep up with the current challenges it faces. Wales is, on the other hand, at an early stage in the development of integrating its services but could be benefiting from a fresh approach. The governments of both countries have been working on reforming their service integration and looking at how far they have come in accelerating effective change may provide lessons for the rest of the UK.

The King’s Fund report of 2013, Four UK Health Systems: Learning from Each Other, concluded that “Northern Ireland represents a missed opportunity to demonstrate on a system-wide basis what can be achieved when the organisational barriers to the integration of health and social care are removed”.

The integrated structures for health and social care services have been in place in Northern Ireland since 1973. The system stood still until the Health and Social Care (Reform) Act (Northern Ireland) 2009, which reduced the number of bodies involved in the administration, commissioning and delivery of services. However, rather than achieving the ideal model for introducing innovative, person-centred care, by the end of 2015 Northern Ireland’s health minister announced that there was still an urgent need for health and social care reform.

Meanwhile, the Welsh Government established seven Local Health Boards (LHBs) in 2009 to plan and commission secondary, primary and community services including mental health, dental, optical and pharmacy services in their local area, with the exception of some more specialised services that three NHS Trusts provide nationally. LHBs established 64 Primary Care Cluster networks consisting of GP practices. They meet under a cluster lead to discuss local needs and priorities, linking practice development plans to work with other partners to improve co-ordination of care and integration of health and social care.

Encouraging collaborative working in Wales

Responding to the fact that Wales has a higher proportion of people over 85 than the other UK countries, the Welsh Government said it was important to fully integrate health and social services and that it believed the solution would not lie in structural change but in encouraging people and organisations to work collaboratively. The Intermediate Care Fund (ICF) was announced in December 2013, initially set at £50 million for 2014–2015. Similar to the Better Care Fund in England, it was created to reduce unnecessary hospital and residential care admissions, as well as prevent delayed discharges and drive forward integration between health, social care, housing and the voluntary sector.

At this time, NHS Wales Chief Executive and Health and Social Services Director General David Sissling told The Guardian newspaper: “I’m sure there are things we can learn (from England) on a reciprocal basis, but I do think that what we are doing seems to be delivering quite promising results in terms of improving patients’ clinical experience and making sure we use resources wisely.”

The Social Services and Wellbeing (Wales) Act 2014 required NHS and social services agencies to collaborate, including using pooled budgets. It gave people a strong involvement in and control over the social care services they use and encouraged the development of new models of integrated and preventive services. Implementation was supported by plans for national learning and development, a national statement of joint working and the “Escalation and Integration Framework”, which brought greater co-ordinated action between the Welsh Government, Healthcare Inspectorate Wales and the Auditor General for Wales.

The Wellbeing of Future Generations (Wales) Act 2015 replaced Local Service Boards with Public Service Boards (PSBs) to co-ordinate and produce integrated plans for health and social care in each local authority area, requiring local authorities and NHS bodies to enter formal partnership agreements.

In 2015, the Welsh Government announced an additional £20 million for health and social care integration projects operating under the ICF. A £6.7 million investment was also announced in May that year for a new IT system, the Community Care Information Solution (CCIS), to allow instant information sharing between different health and care services.

As the 2014 Act came into force in April 2016, funding was made available through the Sustainable Social Services: Delivering Transformation grant to support the transition.

Integrated care partnerships in Northern Ireland

The Health and Social Care (Reform) Act (Northern Ireland) 2009 resulted in more structural reform in Northern Ireland, creating a single large Health and Social Care Board (HSCB), and five large Health and Social Care Trusts (HSC trusts) responsible for the delivery of secondary, primary and community health care, coterminous with five Local Commissioning Groups. The HSCB sits between Northern Ireland’s Department of Health, Social Services and Public Safety (DHSSPS) and the HSC trusts and is responsible for commissioning, managing resources and performance improvement. It is also directly responsible for managing contracts for GP services, dentists, opticians and community pharmacists, which are not provided by the trusts.

However, initiated in 2011, the DHSSPS’s Transforming Your Care: A Review of Health and Social Care in Northern Ireland identified a “clear mismatch between the needs of the population for proactive, integrated and preventive care for chronic conditions, and a health care system where the majority of resources are targeted at specialised, episodic care for acute conditions”, according to the King’s Fund. A recommendation was to establish integrated care partnerships (ICPs) to join together the full range of health and social care services including GPs, community health and social care providers, hospital specialists and representatives of the independent and voluntary sectors. The aim was to provide more care at home, personalise care and shift 5% of hospital funding to primary and community care.

The King’s Fund soon identified failures in implementing the agenda. HSC trusts’ plans apparently failed to pay enough attention to modernisation agendas for social care developed in the other UK countries, user involvement and user control was largely ignored and personalisation was not discussed in enough detail in some plans and the DHSSPS’s strategy. The think tank also concluded in its 2013 report: “Overall there is also a need for new social services legislation, akin to the Bills for England and Wales, which builds on the knowledge that has been acquired since the inception of direct payments. This legislation would clarify and enshrine the rights of service users.”

Criticism from the King’s Fund

The King’s Fund said initial assessments of ICP membership and direction showed the focus was on “herding GPs into further integration within the acute sector, with little consideration given to social care”. It also highlighted how Northern Ireland’s system lacked rigorous evaluation and assessment, had no inter-professional training and lacked good data for evidence of improved patient outcomes.

At the same time it was praising Wales saying “the NHS and social services are now focusing more seriously on capturing the patient’s/client’s experience, measuring outcomes and empowering service users to ensure that services meet their needs — all key elements in integrated care”.

By March 2014, Wales had published A Framework for Delivering Integrated Health and Social Care for Older People with Complex Needs, in partnership with Delivering Local Health Care, which built on existing good progress and accelerated the pace and scale of change by removing remaining barriers to effective collaboration in the sectors.

Positive aspects to Northern Ireland’s history of integration, the King’s Fund said, included co-ordinated care that avoids duplication so that there is one point of entry for people wishing to access health and social services. And some success was being heralded by the Northern HSC Trust, which reported meeting its target of effecting discharge from hospital within 48 hours for 90% of people with complex needs.

Still, the King’s Fund concluded that social care in Northern Ireland needs a package of extra support, including funding and legislation, to bring it up to a par with its health care partners.

The OECD comments

The Organisation for Economic Co-operation and Development (OECD) agreed that all four of the UK countries were looking at how they might best respond to “growing and diversifying social care needs” but that “the Northern Ireland system is lagging behind”.

The OECD’s Reviews of Health Care Quality: United Kingdom 2016 found Northern Ireland’s progress since “Transforming Your Care” to be modest. Although it agreed the country has “an enviable structural advantage over many OECD countries”, it reflected the King’s Fund judgments that the integration of health and social care governance had been poorly exploited, “with funding and service arrangements still in silos and a lack of incentives to encourage change”.

Concerns were raised that the governance structure may be “over engineered and burdensome” and recommendations made for further integration of general practice as “a principal agent for co-ordinating community responses to health and wellbeing needs”. It called for better comparison and benchmarking between trusts, a core set of quality clinical and social care standards and better public reporting of quality of service provision to improve transparency.

Northern Ireland Health Minister Simon Hamilton appointed a committee on reform in December 2015, and a consultation ran up to 12 February 2016 on plans to de-bureaucratise and “de-layer” the health and social care system. He called for the closure of the HSCB, and proposed the creation of a £30 million Health and Social Care Transformation Fund (HSCTF) to be invested in projects and initiatives that are focused on innovation, prevention and collaboration within the sector.

A General Report on the Health and Social Care Sector 2012 to 2013 and 2013 to 2014 by the Public Accounts Committee (PAC) was published in January 2016, confirming that the pace of change was too slow. It recommended a more flexible system, like that which exists in Scotland, which “would involve a move from annual to medium-term financial planning to avoid the annual budgetary constraints and monitoring round bail-out arrangements which currently afflict trusts”.

The aim of the Government’s consultation, Health and Social Care Reform and Transformation — Getting the Structures Right, was to test opinion on whether more structural reform was needed and its response in March 2016 confirmed it would be moving ahead with its agenda. Despite historical advantages, Northern Ireland now seems to be falling behind on the sort of service reform that has been carried out in other UK countries. Its experience illustrates the “Shared Commitment” statement made in 2013, by England’s National Collaboration on Integrated Care and Support, which says: “Integrated care is not about structures, organisations or pathways, nor about the way services are commissioned or funded. It is about individuals and communities having a better experience of care and support, experiencing less inequality and achieving better outcomes.”

This time round, Northern Ireland’s Government will neither be able to afford to neglect focusing on patient outcomes in social care as much as in healthcare nor to ignore personalisation, co-operation, culture change, incentives to innovate and better cross-professional training in its future consultations on reshaping health and social care. Hopefully, any future transformation will earn the same optimism as expressed by the Welsh NHS Confederation, which wrote in The 2016 Challenge: A Vision for NHS Wales that it now believes “Wales, given its size, structure and close links, has a golden opportunity to achieve so much when it comes to integration.”