Community Care
Elliot Bidgood, 9 April 2013
An interesting piece in the GP magazine Pulse today, written by former GP and integrated health expert Jonathan Shapiro, argues the case for better integration between acute and community care in the NHS – “as long as the funding streams of hospital and community care are handled separately, and the incentives for the preferred outcomes are not carefully and precisely aligned, no system can ever function properly”. He assesses how cost inflation and the dominance of the acute hospital sector have become the main problems in the NHS over the last thirty years, leading to little headway being made on health challenges. Meanwhile, he also observes that the main policy response to these problems have been the purchaser-provider split and the strengthening of the role of primary care GPs as “conductors” of streamlined care, but observed that while some activities have shifted away from the acute sector towards the community, making money and information flow this way has been difficult in practice and has held back change. This has meant care remained costly.
Shapiro does appear somewhat critical of competition and its relationship with integration. As I have discussed in past, integration and pluralism in healthcare are arguably not necessarily mutual exclusives under the right circumstances –the US, the Netherlands and Switzerland offer examples of this, although admittedly it will take time to develop such structures in the UK. More broadly, however, the potential benefits of greater integration and community provision in the NHS are clear. As long as there is clear separation between hospital-based and community care, the NHS will remain an episodic ‘sickness service’ and caring for people properly and at efficient cost will remain difficult. The BMA has endorsed this general principle.
Labour’s main policy announcements on health this year have been in this direction – Andy Burnham’s plan for integrated ‘whole-person care’ would put control of NHS budgets in the hands of councils and aim to bring acute, mental and social care together. This is similar to the stance the Liberal Democrats took in 2010. However, questions remain about implementation, costing and the current Labour line on plurality. In 2010, the Conservatives advocated integrated personal budgets and direct payments for social carers, and in government Jeremy Hunt has stressed his commitment to integration. However, some voices in the community care sector appear to have asked for more focus and clarity, if the crucial goal of a more seamless health service is to be achieved.