The purpose of this paper is to take “a long view” of initiatives taken to promote integration between local government and the NHS with the objective of seeking to understand why they have achieved consistently disappointing results.
The paper's analysis is based on an historical overview drawn from official documents and empirical research from the time of the creation of the NHS in 1948. It primarily focuses on the principles shaping the separate but parallel reorganisations of 1974 and their continuing influence up to and including the current White Paper “Liberating the NHS”, and the Health and Social Care Bill.
The fundamental sources of integration barriers today lie in the foundational principles of basing their responsibilities on the skills of providers rather than the needs of service users and their organisational forms on separation rather than interdependence, with national uniformity driving the NHS and local diversity local authorities. In addition, frameworks for integration have been established on a paradigm of seeking to build bridges at the margins of organisations rather than seeking to interweave their mainstream systems and processes.
Future empirical research will be necessary to establish whether the currently proposed arrangements for integration do, in fact, experience the same limited results as previous ones.
Local and national strategies for improving integration should be reviewed in the light of the understandings set out here and local frameworks should seek to align and integrate mainstream systems and processes as far as possible. A thorough and dispassionate analysis should be conducted of whether a free‐standing, single purpose, national organisation still provides the most appropriate structure for delivering health services in light of changing needs, care models, and resources.
The paper offers a distinctive analysis of the possible causes of disappointing outcomes from successive attempts to improve integration. If accepted, it could lead to a radically different approach, first to integration and, ultimately, to the nature of the NHS and local government.
