Integrated Health and Social Care Commissioning

Ken Fullerton

Outline

• Care for older people – a whole system

• Health and Social Care in N. Ireland

• Personal experience

• Potential benefits

• Potential issues

• Potential barriers

“A System produces exactly what it is (was) designed to produce”

What is our system designed to do?

• Differentiate between “Health” and “Social” care

• Ensure that care provided equates to assessed need

• Avoid hospital admission

• Reduce lengths of hospital stay

• Redress imbalance in favour of secondary care

Pathways for Increasing dependency

Primary CarePrimary Care

Acute Secondary

Care

Acute Secondary

Care

Inpatient Rehabilitation

Inpatient Rehabilitation

“Intermediate Care”

“Intermediate Care”

Lesser Dependency

Lesser Dependency

Greater Dependency

Greater Dependency

Social CareSocial Care

Pressures for Increasing Dependency

Insufficient Social SupportIllnessFrailty Functional Decline

Care Home

Care Home

Long term Care Package

Long term Care Package

Social Service Support

Social Service Support

Independent Living

Independent Living

Comprehensive assessment and rehabilitation

X

Geriatric Day Hospital

Geriatric Day HospitalX

Increasing dependency

• Personal consequences– Lessening independence

• Health and social care consequences– Service provision– Increased cost (to the whole system)

• Increasing social care cost may be invisible to healthcare providers

• Healthcare interventions may be inaccessible to social care providers

Costs of stroke care to the system

Budget costs

Secondary Care: £ 636M

Primary Care: £ 507M

Formal social care: £ 1700M

Informal social care: £ 2400M

Budget costs

Secondary Care: £ 636M

Primary Care: £ 507M

Formal social care: £ 1700M

Informal social care: £ 2400M

(10%)

( 7%)

(24%)

(34%)

Costs to social care budget are 40% higher than total healthcare costs

Costs to social care budget are 40% higher than total healthcare costs

Personal/ family costs are two and a half times as high

Personal/ family costs are two and a half times as high

Health and Social Care N Ireland

• Health & Social Care Trusts• Integrated down to Service Group and

increasingly at the level of delivery• Common budgets for healthcare, domiciliary

care and care homes• Care Managers are employed by Trusts, as are

social workers• Single Regional Board, many Health & Social

Care Groups (balance of commissioning unclear)

• No Primary Care Trusts (yet!)

Personal Experience

• Involvement in Integrated Care Teams

• Social care purchasers and providers– Complex packages of care provided at home

• Integrated with care management

• Some nursing and limited OT involvement

• Need for budgetary control

• Opportunity for intervention when care needs (costs) are rising.

HSC Commissioning - Potential Benefits

• Early detection of decline

• Effective method of case management

• Access to comprehensive assessment and rehabilitation

• Prevention of avoidable dependency

• Avoids premature commitment to high cost long term packages or institutionalisation

HSC Commissioning - Potential Risks

• Unwanted effects of integrated commissioning with disparate service provision (slicing the cake)

• Role of primary care unclear

• Further reduction of assessment and rehabilitation facilities

HSC Commissioning - Potential Barriers

• Structures do not exist

• Lack of recognition that Health and Social Care are parts of the same system

• Little direct experience, except local initiatives

• Information systems not linked

• Paucity of research evidence

• It doesn’t fit our current paradigm