Everyone agrees that coordinating care around the patient is important- so why does it keep on not happening?1

Stopping it from not happening.

One of the points I made in yesterday’s post was that there would be a fight between those who argue that over the next ten years the NHS has to use the extra money to do more of the same and those that argue they need to use it to do something different.

But the argument between these two different ways forward is not either/or. No-one intellectually argues that fragmentation of care between the very different parts of the NHS and other aspects of public service is a good thing. Intellectually the argument for coordination has already been won.

But in practice most NHS and social care organisations, most of the time, continue to deliver fragmented care to most members of the public. Indeed as hyper specialisms in NHS care develop, every year some areas of care become more fragmented rather than more coordinated.

How many of the one million consultations for the NHS every 36 hours (plus tens of thousands for social care) are in any way integrative?

So there is no clash of arguments. What we have is a clash between an intellectual argument that has been won and a set of practices which have been unaffected by this.

So many current NHS plans start by saying “As the Five year forward view argues…” but at the end of the year following the plan most practice is still fragmented.

If we roll forward the extra money to 2028 and we have added say 200,000 consultations to that million, on the current real power to change practice – with the current workforce – how many of those 200000 would be integrative and how many fragmenting?

And if I am allowed one more bit of a rant, if you look at the 14 different working groups set up to plan the next 10 years – you will find that most of them are actioned to deliver a plan that will fragment care. They are working away separately on specific fragmented bits of care – run by very good people who are committed to their bit – but by doing so they are not creating the conditions for person-centred coordinated care.

So what should happen straightaway to create better conditions for person centred coordinated care? The first set of actions would be for the regulators to stop stopping it from happening.

David Prior, the new chair designate of NHSE, appearing before the Health Select Committee last week, made the point that in his previous job as Chair of UCL Hospital, no-one would have thanked him if in order to develop integrated care in North London his trust had taken its eye off the ball of being a standalone trust. He made this point in an argument for some legislative change in the way in which national performance management organisations work.

As an ex-MP, he will know that there is not much chance of getting legislation through a very fractious and febrile House of Commons this side of another election. So sorting this out with legislation will take some time. Personally I don’t think we can wait 5 of the 10 years plan which would have to say – “do nothing new for the first five years because it won’t be until then that legislation will be passed”.

So let’s make the changes pre-legislation.

If legislation were passed to bring NHSE and NHSI together next year the vast majority of the staff in the new organisation would be from the two existing organisations and if you wanted a different set of outputs from the new organisation the staff would all have to behave very differently from the way they do at the moment.

The history of the NHS – and all other organisations – demonstrate considerable evidence that passing legislation through Parliament doesn’t really change the behaviour of staff moving from existing organisations into new ones. If you want to change behaviour then you will need it but more importantly have a clear idea as to what new behaviours you want and a cultural change process to develop them.

Therefore legislation to move the current performance management system of health and social care from one that drives further fragmentation to one that drives integration is not only some way off, but will not be the determining factor for the national performance management organisations. What will matter much more is what their staff actually do when they are performance managing both the NHS and social care.

For example if, over this winter, they are primarily managing individual organisations from the perspective of dealing with increased pressure caused by extra demand, then the services delivered will continue to be fragmented.

We would know that national performance management organisations were really managing towards integration if they were to foreground , in local systems, the successful diversions of emergencies away from hospital beds into the patients own homes. This could only be achieved by strong integrated crisis services outside of hospitals

These are very different activities that don’t need a change in legislation to bring about. And the good thing is we will know whether this is happening by November of this year.

If national performance management systems really want  the NHS and social care to develop person-centred coordinated care the first thing to do is to stop stopping them from doing just that.

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