Health and social care delivery needs to change substantially to meet the challenges and opportunities presented by an ageing society, argues Professor Neil Pendleton.
Lifespan is increasing and we know that our health and social needs become more complex as we age. We also know this changing demographic is generating huge challenges for our health and social care system, which can struggle to meet even acceptable standards of care for frail older adults. So how do we respond?
As a hospital consultant, I agree that we can and must do better for older people. Most commentators are calling for radical system change, but what is needed? What are the opportunities presented by devolution and the integration of health and social care in areas such as Greater Manchester? And what improvements can we expect?
Our health care system in the UK is structured around a reactionary approach to illness; symptoms of a specific condition arise, are identified and treated via the appropriate specialism. But this approach is ill-suited to the needs of older people who typically manage a number of concurrent chronic health care problems for which they need to see a variety of different consultants.
What is required is a system geared around the health and wellbeing of the whole person, for the duration of the life-course. This requires a fundamental shift from centralised specialist health care services to comprehensive local health delivery. For this to work, we need a much more connected and collaborative primary, community and secondary health provision. And this is the hope that integrated health and social care presents. In Greater Manchester we now have the mandate to explore this.
The integration of health and social care has long been advocated by leading policy thinkers. For central government, the opportunity is better control of the projected financial pressures for the NHS. At the British Geriatrics Society autumn meeting in Brighton, Professor Chris Ham, CEO of the Kings Fund, addressed the big challenges in delivering integrated care, as well as the significant potential. His words echo a recent edition of the Royal College of Physicians Future Hospital Journal examining the evidence for integration drawing on case studies from New Zealand, Asia and the UK.
The clear message is the need to focus on both the technical and the behavioural challenges. Technically, information systems must be able to share knowledge across organisations, drawing on examples such as that of Canterbury in New Zealand. Behaviourally, evidence shows leaders need to establish and clearly express relationships of trust and mutual respect across the disciplinary cultures and languages in the wider organisation. This shows itself through common and strong governance, quality and performance monitoring. This culture of trust and respect is equally important between the provider and the funder.
In considering opportunities for learning, Japan’s example of care integration offers new insights around the experience of delivering health and social care for older adults. Japan is the world’s prime example of an ageing society. In 2009, 28.4 million Japanese citizens were 65 or older. Of these 4.7 million qualified for long-term care with 7.7 trillion Yen being spent on public care, more than double the figure spent in 2000. 2012 was hailed as ‘year zero’ of community-based integrated care’ in Japan, a multi-faceted approach combining integrated care, community-based care as well as medical care and informal mutual aid.
What is notable from the Japanese example is the overall emphasis on care rather than a medical approach. Devolving organisation and design of older adult integrated care to communities is central to the Japanese structure, reinforced by empirical assessments of effectiveness.
Analysis by Mie Morikawa of Japan’s National Institute of Public Health highlights the importance of including informal mutual aid within this model and integration in local communities. Here, local coordinating centres have been shown to play a key role as does providing user friendly portfolios of available resources A further review by the International Journal of Integrated Care’s editor Nick Goodwin reaffirms the case for the focus of integration having people and communities at its heart, with locally derived solutions and innovations.
But perhaps the biggest opportunity we have for meaningful system change within integration comes from putting the voice of the user at the centre of the health and social care system. Although the evidence we have does not support the ambition of financial savings from integrated health and social care, it does support the promise of a better personal experience. And so it is the input of older people that is the cornerstone of a devolved system of care. The real benefit of integration is for individuals to achieve improved health and wellbeing. Whilst in the short term the outputs from this may be very modest, over the longer term it may result in improved health across all age groups.