Will the coronavirus pandemic provide the necessary impetus for long term health and care integration?

Covid-19 has shifted the dial of discussion surrounding integrated care. Following years of gradual change in the health and care policy landscape, the coronavirus crisis has provided the biggest impetus so far for providers to foster a new model of working.

Speaking at an Integrated Care Journal Virtual Healthcare Breakfast, former Secretary of State for Health Patricia Hewitt placed the journey of system transformation front and centre in her address to delegates. Serving as Health Secretary in the first decade of the century as part of Tony Blair’s Government, Patricia now chairs Norfolk and Waveney Sustainability and Transformation Partnership (STP), soon to become an Integrated Care System (ICS).

Once directing from corridors of Westminster and Whitehall, she now finds herself on the frontline of transforming services.

Breaking barriers

Drawing on local examples of real change manifesting itself, the Norfolk and Waveney STP lead reflected on past challenges getting hospital social workers out of the acute setting and into the community. However, whereas this has traditionally been a point of struggle for system leaders, in Norfolk the transition has become commonplace.

Practices around patient discharge are also undergoing a shift, reflected Patricia. With the previous ‘batch’ approach (that often resulted in delays) rapidly being replaced with a case by case approach, dealing with patients as and when they are medically ready to leave hospital, the process of discharge is improving substantially.

“Previous barriers to sharing health and care records are also dissolving thanks to our coordinated response to Covid-19,” said Patricia.

Further exploring the unexpected outcomes of the past few months, Patricia noted: “In the course of emptying beds to address the worst-case scenario for the pandemic, we solved decade old problems in days.”

In Patricia’s mind, the primary reasons behind this shift are twofold. Firstly, the new sense of teamwork, that has encapsulated much of health sector’s response to Covid-19, has encouraged systems and teams to be more open to changing practice and cooperation. “The simple fact that everyone has been working together on this has meant we have achieved results previously thought impossible,” she stressed.

The second factor lies behind drivers from national policy, where government purse strings have loosened to such an extent that money is currently not a hindrance to change. This mindset, driven by changes from the top, has meant that decisions in social care which would have previously centred around balancing financials are now oriented around delivering the best possible care for residents and patients. This is helped by a long-overdue injection of funds from national government.

We cannot, however, take these changes for granted and assume they will stay for the long-term. “The culture driving these new behaviours needs to be bottled as we move towards the future stages of living with Covid and restarting ‘normal’ care for patients,” said Patricia, insisting that this will help ensure a continued drive towards prevention and integration.

Peeling back the layers

On many levels, the NHS and social care have historically been a “million miles” apart. This makes integrating services in some ways a process of matching corresponding components from either side.

Funding is one layer. Many NHS organisations have become, in Patricia’s words “used to overspending.” Large deficits and backlog bills across some acute trusts and health systems have become a mainstay within the culture of the NHS, with little incentive to push substantive change until now. On the other side, leaders in local government face criminal sanctions unless they balance the books and social care remains indefinitely cash-strapped.

“What we had was two totally different financial frameworks, but with Covid-19, the cheque books have opened,” said Patricia. Of course, that won’t continue indefinitely, but this needs to be an opportunity to create a sustainable funding settlement for social care.

Workforce is another area where progress is starting to show. Norfolk is one of the pioneers for new nurse training associates, a role somewhere between a healthcare assistant and a fully registered nurse. These associates are now being deployed within acute, primary care and in social care settings. “This is what real integration looks like,” said Patricia, “a system where we can share training for common capabilities and integrate career pathways.”

Last year, the NHS Long Term Plan set out a roadmap to cover every region of the UK with ICSs by April 2021. Patricia does not see any reason to abandon this ambition. “As a country, we have an opportunity for a new settlement for social care,” she added. While the NHS has benefited from major policy drivers within the Five Year Forward View, a previous strategy document, and the Long Term Plan now, Patricia wants to see a lasting settlement for social care that will outlive political life cycles. This can only happen through national frameworks that are delivered at a local level.

The digital building blocks for integration

A prerequisite for ‘joining-up’ a health and care system is fostering a digital base to facilitate transformation. Picking up on this perspective and the progress that has been made thus far during the pandemic was Daniel Casson, Digital Development Executive from Care England, who spoke alongside Patricia.

In Daniel’s mind, the lack of interoperability between health and care systems in the past has contributed substantially towards the current, and avoidable, situation in care homes. On the morning the webinar took place, deaths in social care proceeded to rise while those in the NHS continued on their gradual decline. 

One of the key parts of this story is the lack of tech enablement in the care setting. This was reinforced by a point Daniel made that much of the social care sector still lacks access to basic Wi-Fi. “The lack of momentum in digital tech for the care sector is now finally being looked at by the NHS with bodies such as NHSX now negotiating on behalf of the care sector to ensure access to reliable infrastructure,” he said.

Ensuring quality data is accessible is crucial in facilitating a move towards long-term, sustainable integration. “The current crisis has highlighted the sore lack of an integrated data system,” said Daniel. Capacity Tracker and Care Quality Commission (CQC) data collection tools are starting fill these gaps but remain disconnected, with a majority of local authorities in England continuing to rely on their right to collect data independently. This practice stands even though data is being centrally collected and disseminated across most of the sector. “The disparate nature of care services means that there has been an unwillingness to gather data in a collective way,” explained Daniel. This factor had an impact on the spread of Covid-19: while hospitals beds were being cleared very effectively and very quickly, not enough attention was placed on where people were being discharged to and the risks of spreading the infection were not tightly controlled enough.

Adapt to survive

Covid-19 is changing things. Daniel cited reports by regional care managers that feed into local systems as a major steppingstone. “After a few months of lockdown,” he said, “we are starting to recognise the power of reliable data systems.”

As Daniel noted, there should be no going back from the momentous shift towards embracing tech that we are currently seeing. “Digital transformation and true integration in the sector will only create value in people’s quality of life when we have the right infrastructure and facilities in place,” he concluded. 

Also heralding the wave of digital change that has resulted from Covid-19 was Gavin Bashar, Managing Director of Tunstall Healthcare UK & Ireland, the conference’s final speaker. “Digitisation has clearly come along at the right time,” reflected Gavin. The health and care technology company he leads has long pioneered person-centred solutions to support vulnerable people with a range of monitoring solutions. “Twenty-five years ago, these opportunities were simply not there,” he added.

Exploring this theme, Gavin stressed that in implementing any integrated solution, whether that be digital or otherwise, the benefit must reflect the nature of integration and be collective. “solutions must not just benefit one side of the equation,” he said, “and evidence-based healthcare will be needed to drive this change.”

This is particularly pertinent during the Covid-19 crisis where the political need to provide quick solutions presents a danger that better and more sustainable solutions are missed. Drawing the balance between meeting immediate needs and taking a more holistic view on the longer-term requirements for patients, residents and the sector is proving critically important, the speakers reflected.

“If there could be any silver lining, it is that the appetite for digital change has been highlighted by Covid-19,” said Gavin. In his view, the adoption of remote monitoring, which has been enforced by this crisis, should now become standard practice. It seemed that a consensus was reached; a continued and accelerated approach to health and care integration through digital transformation is now absolutely essential.