Editorial
Article Type: Editorial From: Journal of Integrated Care, Volume 20, Issue 4
Since our last issue there have been two significant events which need to be considered here. The Health and Social Care Act 2012 has passed into law,heralding the start of the era of clinical commissioning. More recently, the Department of Health has published the results of the national evaluation of its pilots of integrated care organisations.
This journal welcomed the coalition’s original White Paper, through which the Secretary of State dealt himself a very strong hand to stimulate locally integrated health and social care services (consistent with the sixth law of Leutz, 2005) and to strengthen the role of local government in matters of health. Mr Lansley clearly wanted to let go of central control. He then proceeded to play that hand very amateurishly, and had to be rescued by his playing partner, the Prime Minister, at one crucial point. As a result, there has to be some fear that the NHS will still remain a highly centralised bureaucracy in the hands of its current senior executives, thus making it hard for local government and social care to be anything other than a minority voice. If this centralising tendency also emasculates the clinical commissioners there will be no innovation, and the original intentions of the Act will have been thwarted in practice. We will see later what happens on the ground … and,as an aside to this, do read Ed Mitchell’s column in this issue on the simultaneously enacted Localism Act 2012!
Some relevant lessons could, however, be drawn from experiences in Germany over the last few years, which are revealed in our lead article in this issue. It is well-worth reading carefully, even though we may all risk some misinterpretation of the insurance-based German system which is unfamiliar to us. But what the article reveals is that the insurers (who can roughly be equated with our commissioners, i.e. taking on the risk and paying providers)have benefitted from the role of integrator which has been taken on by a new company, Gesundes Kinzigtal GmbH. In some ways, the company acts in the role of accountable care organisation which was advocated in our last issue by David Wellbourn, and is certainly “aligning incentives across a variety of providers to achieve practical integration driven by outcomes” (Liddell and Wellbourn, 2012).
The story of Gesundes Kinzigtal is enhanced by its mission to develop a public health dimension in its task, seeking to intervene early with educational initiatives and support for self-care. Although the programme in Kinzigtal is still work-in-progress, the results outlined in the article suggest we should take an interest in the model. It is about “whole system management”,while still promoting individual choice. Plenty of detail is provided by Helmut Hildebrandt and his colleagues to fuel our thinking. It may be impossible to transfer the approach directly into our system, and there are now plenty of English examples of integration with social care (which is yet to be developed in Kinzigtal), but the courage to take responsibility for the whole system and to introduce new ways of working together should provide some inspiration to us after the harrowing battle over the new Act.
Turning now to the evaluation of Labour’s programme of integrated care pilots (RAND Europe/Ernst and Young LLP, 2012), feelings of disappointment seem to abound. For people wanting clearer evidence on whether or not to undertake the effort of integrating local services, there is not much help either way. For a government actively promoting integrated healthcare and integrated health and social care, the report provides no new ammunition. For this journal, which has repeatedly decried the lack of investment in research into integrated care over the last decade, it is excruciating that the massive investment which must have gone into this study has been squandered in an over-elaborate methodology for a pilot programme lasting only two years: any fool would have known at the start that the projects would be slow to get going and that the data capable of being collected would be limited. The last straw was for things that were already well known and understood before the pilots were evaluated to be trumpeted as revelations for “decision makers”, for example:
Do not underestimate the challenges involved.
Do not lose sight of the needs and preferences of patients and service users.
Be creative in developing approaches to integration.
Expect the unexpected.
Trite, or what? The evidence base applied by Phillip Lunts in the tiny study of change management in integration reported in this issue could have confirmed all this, and he reveals in his findings the consequences arising during implementation. The national study was the wrong evaluation, at the wrong time by the wrong people.
By coincidence, leaders of one of the 16 pilots (Norfolk) have undertaken their own evaluation and produced an article which appears in this issue. It is one of the six pilots which applied a case management focus, a feature acknowledged in the national evaluation as producing better results in respect of the reduction of secondary care costs (but not emergency admissions, as intended). The evaluation of the Norfolk data by Tucker and Burgis is obviously not as independent as the national study, but they do take a different view. The article is therefore interesting in its own right and also as a comparison to the generalised national conclusions.
If there are more local evaluations from the other 15 pilots, we would be pleased to receive them here.
Peter Thistlethwaite
