No prevention without integration?

One of the pleasures of being involved in the White Paper engagement exercise, Caring for our Future, is that very clever and experienced people send you interesting and insightful thoughts and evidence. The challenge is reading it all. I’m co-leading the reference group looking at the issue of Prevention: what is it; how can we encourage people to invest preventatively in a time of budget cuts;  how much can be done by the state, and how much only by individuals, families and communities? A submission which has made a big impact on us is from Andrew Kerslake at the Institute of Public Care. IPC and Oxfordshire County Council carried out research in 2008/09 and found that, for instance, urinary incontinence  appears to be one of the leading health characteristics of people who are admitted to care homes (45% of people living in care homes), but nationally, a third of people with incontinence remain undiagnosed and health service responses tend to focus on management (a rationed supply of pads) rather than treatment.

This seems to back up a point made by a number of people, which is that previous attempts to make the case for prevention stick, have been too focused on just health, or just social care, whereas a more integrated approach is needed to make real savings without cost shunting or ignoring the complexities of people’s needs and lives.

In other words, there is no effective prevention without integration. If we try to prevent poor outcomes in only one domain of someone’s life we will probably fail to demonstrate a really clear outcome. If we try to create savings for one sector, such as health or social care, we may very well create costs in another. So we need to be able to enable people to look across their health, well-being, housing, employment/ volunteering and to think about solutions which lie in their relationships with family, neighbours and communities as well as in themselves.

This line of argument suggests that the only saving worth making is a saving to the whole public purse, which is of course that much harder to measure. Perhaps a more achievable step towards that might be to start routinely measuring costs and savings of interventions to health, social care and benefits bills. We might be able to boil that down even further by homing in on one or two key areas of spend within those domains, such as delayed discharge and use of primary care within health, use of home care and residential care within council budgets, and uptake of benefits.

Savings to services and the state can often only be measured at population level, but it feels from people’s submissions to the engagement process that there is enough evidence out there to make economic links between a number of key outcomes which can be scored and tracked at an individual level (e.g. isolation, falls, self-reported mental health, addressing incontinence, caring 50+ hours per week, ability to participate in activities outside the home) and likely costs to services. A holistic approach of this kind has the opportunity to find common ground between the point of view which says, ‘Success in prevention is all about making a saving’, and the opposing view which says, ‘If you only focus on savings, you medicalise the issue and divide people into the ‘fixable’ and the ‘not fixable’, creating a two tier system and perverse incentives to ignore the most vulnerable’. Looking at outcomes, and their related costs, across several domains and sectors gives us the chance to recognise that, for instance, isolation is undesirable, and costly, whether you are someone just coming onto a council’s radar, or someone living in a care home.

This month, we will be testing early ideas such as these in seminars involving all of the reference groups. If you think we are barking up the wrong tree, or if you have relevant evidence to submit, there’s still time to make your submission via the website: http://caringforourfuture.dh.gov.uk/

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