Following a global recession, public services in many countries are preparing themselves for the worst in terms of future public spending. In the UK (which seems worse hit than many), the potential cuts are substantial. After year-on-year funding increases to bring England closer to European levels of health care spending, the National Health Service now faces the very real prospect of active cuts. With many of the main political parties pledging to protect the NHS as much as possible, other services—such as adult social care—could be hit to an even greater extent. At a time when the population in ageing and demand increasing, services could find themselves with the real prospect of having to meet ever greater need with less and less resource. According to one estimate, NHS funding could fall by around two per cent per year in real terms from 2011 to 2014—requiring the NHS to find savings of around £15–20 billion over three years . This, Ham argues, could represent “the longest, sustained period of disinvestment in the history of the NHS” [1, p. 2].
Against this background, local health and social care communities are bracing themselves for the worst, and trying their best to prepare for what might be coming. However, how they react will be fascinating to watch—and could either be a major incentive towards integrated care or a major barrier to progress. In some areas, the natural response will probably be for single agencies and professions to retreat back further into their organisational/professional identity, more jealously guarding their boundaries and their budgets. Under this approach the aim is to carry on with more of the same, but to try our best to do it even harder and even more efficiently (perhaps with X% savings made en route). In many ways, this is an understandable reaction, but also a deeply unfortunate one—and is likely to lead to a series of negative organisational behaviours, short-term expediencies and widespread cost-shunting. Of course, ‘cost-shunting’ is a very easy term for a much harsher reality—as it is not just the cost that gets shunted, but often the individual patient as well.
In contrast, other areas might respond by viewing necessity as the mother of invention. Under this scenario, things may be so bad that ‘more of the same’ will not be enough—indeed, we might even conclude that it was ‘more of the same’ that got us in this mess in the first place. With this approach, local services might realise that only something fundamentally different will be sufficient to come through the current economic crisis—and that all local services are in this together.
For those areas sufficiently broad and flexible in their thinking, a key route forward is likely to be integrated care. Whilst those who seek to retreat into their organisational silos will damage existing relationships, those who approach the financial situation together are likely to conclude that the only way forward is to make the best possible use of scarce public resources, working together for better patient outcomes and safer, more effective care. In practice, this might also help to develop the evidence base around the outcomes of integrated care. While working together with scarce resources must be intuitively better than working separately, the evidence about exactly what and how this might impact on costs, services and outcomes is underdeveloped—and this could be an ideal opportunity to learn much more about these issues.
Viewed from this angle, integrated care could be the only show in town—the one approach to service delivery that could bring us through a period of austerity and out the other side. If they had to guess, most commentators might suspect that too many areas will follow the initially easier but ultimately doomed approach of working in silos—with too few trying to reach joint solutions and work in genuinely different ways. Over the coming months and years a key role of publications, such as the International Journal of Integrated Care and those who write in, read and support it may well be to continue to make the case for integrated care in increasingly difficult circumstances (in the hope that this will be enough to persuade enough people to respond to the current crisis in more joined-up ways).
Health in a cold climate. London: Nuffield Trust; 2009.