Last week two key documents were published which fuelled further some thinking I had been doing for some time. The first was the Kings Fund summary on integrated care: Integrated Care – What is it? Does it work? What does it mean for the NHS? . This paper summarises and brings up to date a Kings Fund review from late last year on Clinical and Service integration, but places it in the wider context of Integrated Care. The second publication is the Royal Society of Arts’ Journal, which this month linked health and social care with wider social networks, and by extension to place. To some degree, the underlying philosophy and economy of these issues delegates questions such as the Health & Social Care Bill and what happens to GPs to a second order of importance.
The linkage of care services to place is one which fascinates me, and one which is significantly underrated. Yet it is a fundamental question if we are to address the needs of older or vulnerable in our communities. For the way place determines frameworks of care, and the way care networks can help to define a place, is a subject area which has yet to be really thought through. In the UK we talk about ‘postcode lotteries’ disparagingly, referring to variation in care by institutions. Yet there is another form of postcode lottery which is rarely talked about: having the luck in later years to live in a place which can provide the social networks that keep us out of what the professionals call ‘care pathways’ and which might more accurately be described as a care plug hole.
I agree with many others who consider that it is the job of local government to focus much more on managing the demand side of care and to encourage the development of societal care networks, rather than to simply focus on the supply side of care commissioning. In the London Borough that I live in, Southwark Circle is doing much to develop just such a network of place.
Yet simply addressing the demand side is not enough to help manage the challenges we will face in the future, and place sensitive commissioning will be critical to ensure the flexibility of care that will be needed. Integrated care at the human level will be extremely difficult to achieve, but the Kings Fund paper points at some useful ideas about how they can be better integrated and made more responsive across the public sector. It suggests a mix of macro (population based) care, meso (group based) care and micro (personal) care, all of which would be integrated between providers. Such care frameworks are joined back to place, in particular through the community, housing or environment settings that they are delivered in. Of particular importance in this context is the extent to which quality of life might vary depending on the numerical economies of care. An integrated care housing setting for older people might be most efficient in units of, say, 50 people; but will I feel empowered or anonymised by this environment? Does where I live become a community hub, which welcomes in people of all ages or a ghetto? Are there risks that might need to be, or indeed can be, designed out?All the above questions have a critical impact on culture and place and there are any number of attributions to wide variations on the adage that a society will be judged on how it treats its weakest members’.
What this all means to me is that local communities need to think about what they do, in integrated care and place terms, to enable older and vulnerable people to live the fullest possible life and to help them to identify and choose the best possible care when they need it. In practical terms I think that we need to do three things:
Amongst a myriad of efforts, the above requires:
All so idealistic, but perhaps we need to be. Will an older person, or someone with physical or learning disabilities say that the community and the place in which they live is their home, where they have control of their lives, can achieve and relate to other people, or is it somewhere that is where they wait, more of a prison maybe. Regardless of the national economic position and the amount of money available to the public sector, we need to be able to develop a better answer to such challenges.