The past few weeks have been a difficult time for the development of the holy grail of health policy – integrated care: an NHS trust in the Midlands that was supposed to hold a ‘landmark’ integrated care contract worth £360m is set to be wound-down, and a contract in the Wirral heralded as achieving ‘truly integrated’ health and social care service is to be terminated after six years as it brought no improvements in care. Alongside these failures, came a briefing from the Nuffield Trust and The Health Foundation that places much of the blame for the failure of integration in health and social care on the lack of change in working cultures in the NHS and social care to support collaboration.
Writing in the HSJ, Helen Buckingham, director of strategy and operations at the Nuffield Trust, and Sarah Reed, improvement fellow at The Health Foundation, note that “Integration has too often felt removed from the day job of those working in services, and from patients and service users who would gain so much from seeing that more joined-up care delivery actually happens.”
The Black Country, once considered a leader in developing integrated care, will now see the scrapping of a trust set up to hold a £360m contract for the integration of health and social care across the region, Dudley Integrated Health and Care Trust (DIHC).
DIHC, which began development over eight years ago, is now going to be wound down or merged with another trust by the Black Country Integrated Care Board (ICB).
Initially the development of DHIC was actively backed by NHS England, which designed a new type of contract for the trust to hold as an Integrated Care Provider (ICP).
However, it was not universally supported across the region, in particular at The Dudley Group Foundation Trust, the local acute trust. In July 2020, senior clinicians at the acute trust wrote a letter to the CCG, both trusts involved, and NHS England, asking that a risk/benefit review of the care model be carried out and the development be paused for 12 months.
A review produced by Mike Richards for NHSE warned of “really poor relationships” and “hostility” within the Dudley system, in particular between leaders and clinicians working at the acute trust and the new NHS trust.
In April 2021 Dudley CCG said it was ready to transfer the final £360m worth of services to the new NHS trust, DHIC, but this never happened as NHSE intervened and stopped the transfer.
DHIC was supposed to hold a single contract for primary care, community health, community mental health, and some public health services. Some services were transferred, but not the community services run by local acute provider Dudley Group Foundation Trust, the largest component of the new contract.
At the moment, DIHC runs only around £20m worth of services, for improving access to psychological therapies and a primary care mental health service, plus some commissioning activities.
In contrast, in the Wirral a contract that integrated health and social care at a single trust has been running for almost six years, but is being axed following a review that found no improvement in the service.
In June 2017, Wirral Council awarded a contract for the major part of its social care services to Wirral Community Health Care Foundation Trust (WCHC). The contract had an annual cost of £10m.
Around 240 staff were transferred from the council to WCHC, including those who commission social care provision and assessment and reablement workers. The trust also had responsibility over the wider social care budget.
WCHC has stated it has made Wirral one of the few places in the country to have made “significant progress towards truly integrated health and care provision”. However, despite the integration a recent review of the contract by the council concluded: “Whilst services have remained safe and of a good quality the review has not evidenced significant and sustained improvement of service outcomes for people through delivering under the current delegated arrangements.”
As a result of the review and other considerations surrounding cross-working within the council, the council has decided to bring the social care services back in house.
Now, however, the exact timing of the contract ending has become uncertain for everyone involved, including the over 200 staff involved. The council has suggested an extension to September 2024, but WCHC has told the council that they had concerns regarding the one year extension and they want a longer contract or it would be transferred back to the Council by 1 April 2023.
The two organisations are reported to be now in discussions about agreeing a compromise, which could be for the contract to run until the current end date of September 2023.
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