Integration or co-operation?

I’ve been in a couple of roundtables recently in which the Labour party has outlined their plans for integrated care. It’s fairly broad and high level stuff at the moment, but a key part of their proposal is that health, care and perhaps other aspects of the welfare and support system will be integrated with a single budget, with, as I understand it, councils in the lead on commissioning (presumably using the new Health and Wellbeing Board structures) and NHS organisations acting as delivery bodies, with less emphasis on increasing competition from independent providers.

It’s an alluring idea, which addresses a split between health and social care which has never ‘worked’ and was hotly debated when the NHS was created in 1948. Back then, the NHS could focus on illness treatment and most people got any ‘social care’ they received from their families, not the state. Now the NHS and social care need to be effective and sustainable for massively increased numbers of people with manageable long term conditions, not short illnesses likely to be either treated or fatal.

I’ve blogged before about the need to integrate not just services, but the informal/unpaid support system and the formal/ paid service system. An integration of health and care will not automatically achieve this. A recurring phrase in today’s discussion, for instance, was ‘patient rights’. There was a little, but much less, about citizens (not patients) and shared responsibilities. It would be easy to integrate around the existing public services power bases of hospitals and professionals, not around individuals, families and communities. This would be to integrate illness treatment services, not health and well being (eco)systems.

The language of rights in relation to health and well being is interesting. Charities and politicians alike are more comfortable talking about rights and entitlements than about responsibilities. This can mean that charities contribute to ‘clientism’ and that politicians can’t deliver on promises. Because I can have a right to an illness treatment service, but not to health, much less well-being or to live without loneliness. Those are all vitally important are not something a service can deliver: they are achieved only as shared responsibilities.

Responsibilties are often over-simplified into purely financial terms, or into debates about whether smokers derserve NHS treatment and so on. It should not need pointing out in the current climate that promises of unlimited entitlements are rarely kept. Six million family carers know all about the responsibilities to provide unpaid contributions hidden in the current system. So do people who spend time organising a Direct Payment funded package. In both cases, it is not necessarily having the responsibility which is problematic – indeed this can be something which people value greatly. The problem lies in the lack of recognition of citizens’ contributions by professionals, and a dearth of training, back-up and support from services when things get tough.

We were asked today what we’d demand of the Labour party if it gained power. I would demand a system with no hidden or unrecognised responsibilities in it: a clear, fair and realistic contract between state and individual or family unit, so that if I am caring for myself or a relative I feel I’m an equal part of a team, alongside any professionals involved. The entitlement I would demand would be to all the tools, information and support I feel I need to contribute to my own health and well-being, and my family’s.

This is not a new idea and it’s one which is arguably embedded in the history of the Labour party through the co-operative movement. I wrote an article for Respublica recently which explored that idea in more detail: Making it Mutual: The ownership revolution that Britain needs

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