WWW.IPPR.

ORG

IntegratingHealthand
SocialCareBudgets
Acasefordebate
OlgaMrinska

January2010
©ippr2010

InstituteforPublicPolicyResearch
Challengingideas– Changingpolicy
2 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

Contents
Executivesummary................................................................................................................ 3
1.Introduction....................................................................................................................... 4
2.Integratinghealthandsocialcarebudgets:thepolicycontext........................................ 5
3.Costsandsavings .............................................................................................................. 8
4.Decentralisation................................................................................................................ 8
5.Prevention ...................................................................................................................... 10
6.Therationaleforintegratingbudgets ............................................................................. 12
7.Relevantpracticesandpilots .......................................................................................... 15
8.Conclusions ..................................................................................................................... 16
References ............................................................................................................................17

Aboutippr
TheInstituteforPublicPolicyResearch(ippr)istheUK’sleadingprogressivethinktank,
producingcutting-edgeresearchandinnovativepolicyideasforajust,democraticand
sustainableworld.
Since1988,wehavebeenattheforefrontofprogressivedebateandpolicymakinginthe
UK.Throughourindependentresearchandanalysiswedefinenewagendasforchangeand
providepracticalsolutionstochallengesacrossthefullrangeofpublicpolicyissues.
WithofficesinbothLondonandNewcastle,weensureouroutlookisasbroad-basedas
possible,whileourGlobalChangeprogrammeextendsourpartnershipsandinfluence
beyondtheUK,givingusatrulyworld-classreputationforhighqualityresearch.
ippr,30-32SouthamptonStreet,LondonWC2E7RA.Tel:+44(0)2074706100E:info@ippr.org
www.ippr.org.RegisteredCharityNo.800065

ThispaperwasfirstpublishedinJanuary2010.©ippr2010

Abouttheauthor
OlgaMrinskaisanindependentconsultantandipprResearchAssociate.Shewaspreviously
ResearchDirectoratipprnorth.Herareasofinterestincluderegionalpolicyandgovernance,
localeconomicdevelopment,andeconomicaspectsofpublicservicesreform.

Acknowledgements
ipprwouldliketoexpressitsgratitudetoWyethforfinancialsupportofthisproject.The
authorisgratefultoipprcolleaguesfortheircommentsonthedraftpaper.
3 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

Executivesummary
Overthelastdecade,Britain’spublicserviceshavefacedanumberofchallengesrelatedtoa
changingpopulationprofile,growingdemandsfrommoreassertiveusers,andtheneedfora
moresustainablemodelofdelivery.TheUK’shugefiscaldeficitwillnowaddthemost
pressingandcomplicatedchallengeofall:cuttingexpenditureonpublicserviceswhile
maintainingqualityandusersatisfaction.
Thispaperopensadebatearoundtheprospectsforamoreinnovative,moreresponsive
modelofpublicservicesforgroupsofuserswithcomplexneeds.Thismodelrevolvesaround
integratinghealthcareandsocialcarebudgets.Thepaperanalysesthepolicylandscape,the
keydeterminantsofmodernpublicservicesandthemainfinancialaspectsofintegrated
budgets.Itrecognisesthattherearetwodifferentapproachestointegratingbudgets–an
‘individually-centred’approachanda‘system-centred’approach–andarguesthatthebest
waytocreateamoreresponsiveandfinanciallyeffectiveservicemodelistocombinethe
two.
Theindividually-centredapproachtointegrationpromotesenhancedcitizenshiprightsinthe
planninganddeliveryofpublicservicesandrequiresfrontlineexpertisetoplaytheleading
role.Bycontrast,thesystem-centredapproachusesvariousadministrativemeasurestoseek
greaterfinancialandoperationalefficiencyandisprimarilydrivenbycentralgovernment.
Thepaperanalysesthestrengthsandweaknessesofeachapproachanddiscussestheir
currentuneasyco-existence.
Atthemoment,attemptsatlinkinghealthandsocialcarebudgetsareoftenfragmentedand
areplannedandimplementedwithoutdueregardtoothersimilarinitiativeshappeningat
eitherthelocalornationallevels.Forintegrationtofindtheoptimalbalanceof
personalisation,accountabilityandfinancialefficiency,centralgovernmentwillneedtojoin
forceswithlocalgovernments,frontlineprofessionals,usergroups,andthevoluntaryand
privatesectorsinordertobuildsynergiesbetweendifferentactivitystreams.Individually
centredandsystem-centredfinancialinnovationsarebestusedtogether,witheach
addressingdifferentsegmentsofpublicservicesasappropriatetothecontext.
Itwillalsobecrucialtodevelopmorerigorousanalysisofthefinancialimplicationsof
integratingservicesandtheirbudgets,asthereislittleevidenceyetoftheeffectivenessand
efficiencyofdoingso.Atthesametime,itisalsoimportanttolookatthecostsandbenefits
ofincreasingtheshareofpreventiveservicesinhealthandsocialcare,asthisshouldbea
wayofincreasingthefinancialviabilityofservices.Boththesetasksrequirebetterquality
dataandgreaterengagementfromthemainstakeholders.
4 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

1.Introduction
Thispaperconsidersthepreconditionsandcoreprinciplesforintegratinghealthandsocial
carebudgetsinthecontextofchangingneedsandsignificantstrainsonpublicfinances.
PublicservicesinEnglandcurrentlyfaceanumberofsignificantchallengeswithregardto
healthandsocialcare:
•Changingdemographicpatterns,includinganageingpopulationthathasgrowingand
morecomplexcareneeds
•Moreassertiveserviceusers,whoexpectmoreflexibilityandcontrol
•Adeteriorationinsomeaspectsofthepublic’sphysicalhealth,particularlythesteady
growthinobesity
•Thedrivetowardsmoresustainablewaysoflivinganda‘green’economy
•Ashifttowardsagreaterdecentralisationofpowersfromthecentralgovernmentto
localauthorities
And,aboveall:
•Theprospectofreal-termcutsinpublicspendingfrom2011onwards.(Dolphin2009)
Meetingthesechallengeswillrequirenewapproachestothedesignandprovisionofcore
publicservices,includinghealthcareandsocialcare.Thesenewapproacheswillrequire
financialandorganisationalinnovations,andmustprecipitateashiftawayfromreactive
healthandsocialcaretowardsamorepreventiveapproach.
Theideaofintegratinghealthandsocialcarebudgetshasbeenwidelydiscussedatthe
academicandprofessionallevels,butsofarhasbeenexploredonlytentativelyintermsof
concreteactionsandpolicyinstruments.Thereisstillverylimitedevidenceregardingthe
effectivenessorotherwiseofsuchanapproach,andmostinitiativesarestillatthepiloting
stage(seediscussioninSection7).

Whatdowemeanbyintegration?
Inthispaper,weuseintegrationtorefertotheprovisionofservices– originatingfrom
differentagenciesandfundedfromdifferentfinancialstreams– inajoined-upandcoherent
way,withsingleoperationalandfinancialsystemsinplace,inordertoallowforgreater
complementarityandlesssystemwastage.Integrationusuallyoccursatthelocallevel,
thoughitisplausibletointegratefundingstreamsathigherlevelsofgovernance.For
example,theGovernmentrecentlyoutlinedplanstocreatesinglebudgetsforcomplexissues
thatarecurrentlybeingdeliveredbymultipledepartments(forexample,climatechange,
combatingobesity)(HMGovernment2009,TheTimes2009).Thiswillnecessitate
fundamentalchangesinadministrativeprocedures,marketsandrelationshipsbetween
professionalsfromdifferentspheresandserviceusers.
Therearemanysignificantaspectsofintegratinghealthandsocialcarebudgetswhichneed
tobethoroughlyexamined.Theseinclude:
•Theimpactandimplicationsofintegratedbudgetsforindividuals,professionals,and
servicemanagers
•Howtoadaptadministrativeandfinancialsystemstomanageintegratedbudgets
•Howintegratedbudgetsaffectcommissioningpractices
•Theneedfornewandmorerobustsafeguardingmechanismsandprofessional
training/supportofstaff
•Theneedfornewgovernancestructuresandcollaborativeinstrumentsatthelocaland
nationallevels
5 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

•Questionsaboutinformationprovisionand‘navigating’servicesforindividualusers
•Psychologicalaspectsrelatingtosatisfactionwiththisformofserviceprovision.
Itisbeyondthescopeofthispapertoprovideacomprehensiveanalysisofalltheissues
surroundingtheintegrationofservicesandfundingstreams.Anumberofotherresearchand
analyticalreportspreparedbyippr1 andotherorganisationsprovideusefulresearchand
analysisonsomeofthemattersoutlinedabove.Thispaperfocusesonwideningthefieldof
debatearoundtwokeyissues–financialefficiencyandtheresponsivenessofpublicservices
totheindividualneedsofserviceusers.Itconsidershowthiscanbedone,lookingatseveral
factorsincluding:financialandadministrativeinnovation;personalisation;enhanced
citizenshiprights;morepreventivecare;andchangingresponsibilitiesinhealthcareandsocial
services.

2.Integratinghealthandsocialcarebudgets:the
policycontext
Thepolicylandscapeintheareaofintegratedbudgetsisquitefragmented,withonlyafew
comprehensivepolicyinitiativesregardingintegrationofhealthandsocialcareservices,for
exampleStayinginControl,ConnectedCare,andDepartmentofHealthIntegratedCare
pilots(seeSection7below).Therehastraditionallybeenariftbetweenhealthandsocial
careservices,whichweredevelopedanddeliveredbydifferentagenciesandcontrolled
throughdifferenttiersofgovernment.
Fromtheperspectiveofmanyusers,however,healthandsocialcarehavealwaysbeentwo
sidesofthesamecoin.Forpeoplewithlong-termconditionsanddisabilitiesinparticular,it
isoftendifficulttodrawthelinebetweenhealthcareandsocialcareservices,andthey
expectbothsystemstoworkcloselytogethertoaddresstheirneedsandconcerns.Forthese
groupsofclients,welfareservicesandhousingarealsocloselyrelatedtocare,thoughthese
arequitedistinctiveareasofgovernmentandthusthereislessspaceforconfusion.
Nonetheless,thereisgrowingdemandforalloftheseservicestobebetteralignedinorder
tomeetcomplexhealthandcareneedsforsomecategoriesofusers(theIntegratedCare
andConnectingCarepilotsaredesignedtotestthiscomprehensiveintegrationofdifferent
services).
Thereisaplethoraofregulations,pilotsanddiscussionsrelatingtotheareasofintegrated
care(followingtheHealthAct1999),self-directedsupportinsocialcareandhealthcare,
individualandpersonalbudgets2,andthenewconceptofcitizenshipinpublicservices.
Thereisalsoastrandofpolicythinkingthatarguesthatitispossibletocutthecostsof
servicesbyjoiningupandstreamliningbudgetsofdifferentservicesatthelocallevel.
Thoughsuchmeasuresareimportant,theyrepresentonlypartofthepictureandmany
aspectsofintegratedhealthandsocialcarewillstillrequirepoliticalwillandpolicyrigourif
reformisevertotakehold.
Thehistoryofintegratinghealthandsocialcareservicesgoesbacktothebeginningofthe
NewLabourerain1997.Thenewgovernmentcommitteditselftodestroying‘theBerlin

1.SeeforexampleMcNeil(2009),Ben-GalimandMcNeil(forthcoming),Moullin(2008)
2.Personalbudgetsareanallocationoffundinggiventousersafteranassessmentwhichshouldbe
sufficienttomeettheirassessedneeds.Individualbudgetsdifferfrompersonalbudgetssincetheycover
amultitudeoffundingstreams,besidesadultsocialcare,suchasSupportingPeople,DisabledFacilities
Grant,IndependentLivingFunds,AccesstoWorkandcommunityequipmentservices(CommunityCare
2009).
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Wall’betweensocialandhealthcareserviceswhichhadappearedafterdramaticreformsto
communitycarein1974.OneofthekeystepsinthisdirectionwastheHealthActof1999,
whichallowedvoluntarypartnershipsbetweenlocalauthoritiesandNHSbodies.Section31
oftheActprovideddetailsabouthowsuchpartnershipsshouldfunction.Thesemeasures
werelaterintegratedintothenewHealthAct2006(Section75)andremainoneofthe
fundamentalsofintegratedcareinEngland.Therearealsoseveralstatutoryandnon-
statutoryinstrumentsforintegratingbudgets,forexamplecaretrusts,childrentrusts,grants
arrangements,andsoon.Theintegrationoffundsthroughpooledandalignedbudgets3 has
becomeespeciallypopularinEnglandoverthelast10years.
TheHealthAct1999enabledtheestablishmentofvariousinter-sectoralpartnershipsand
initiatives,suchasSureStart,HealthyLivingCentresandHealthActionZones.Later
assessmentsoftheseinitiativesdemonstratedthattheintegratedservicesprovidedinthese
centresareeffectiveforthetargetedgroupsofpopulation(forexample,childrenandadults
fromdisadvantagedhouseholdswithlowincomeandmultipleproblems).Thereisalsoan
infrastructuretosupportjoined-upworkingwhichwascreatedasaresultofpolicy
decentralisationinEngland.TheLocalStrategicPartnerships(LSP)andthematicpartnerships
betweenPrimaryCareTrusts(PCTs)andlocalauthoritiescreatedforthedevelopmentand
deliveryoflocalstrategiesareeffectiveforumsfordesigninganddeliveringintegrated
services(seeSection4below).
Acrossthecountry,therearehundredsofcasesofpoolingandaligningbudgetsin
healthcareandsocialcare,especiallyinareaslikementalhealth,purchaseofequipmentfor
disabledpeople,andcareforolderpeopleandpeoplewithlong-termconditions.Insuch
cases,poolingandaligningbudgetshasprovedtobeespeciallyeffective.Thecreationof
caretrustsin2000,whicharedeliveringbothhealthandsocialcareservices,wasanother
incrementalstepintheprocessofservicesintegration(Weeks2005).
However,accordingtoarecentreportfromtheAuditCommission,thereisnostrong
evidencethatthesetypesofbudgetflexibilities(poolingandaligning)havebrought
substantialeconomiesinadministrativeoroperationalcosts(AuditCommission2009).
Moreover,asurveyoforganisationsparticipatinginsuchpartnershipsconductedbythe
AuditCommissiondiscoveredthatlocalpartnershaddonelittletoassesstheeffectivenessof
thesearrangementsinachievingbetterhealthandwellbeingoutcomesforserviceusers.It
alsoidentifiedmultipleproblemsinintegratingbudgetswhichwillrequirefurtherchangesto
theregulatoryframeworksandfinancialandadministrativeproceduresofcoreservicesin
ordertoallowgreaterflexibilityandlocalinitiative.
Self-directedsupport,whichempowerspeopletomakedecisionsrelatedtotheirownlives,is
perceivedasthekeyinstrumentforachievinganewlevelofcitizenshipinpublicservices.
However,theDepartmentofHealthhasuntilrecentlybeenverycriticalofutilisingthis
modelintheNHS(NHSConfederation2009),expressingconcernsthatitmightgoagainst
thecoreprinciplethat‘careshouldbefreeatthepointofuse’(DepartmentofHealth
2006).However,thisattitudehasgraduallychangedsince2007,andin2008theNHSNext
StageReviewoutlinedaplantoprovidecertainNHSservicesbasedonself-directedsupport
andpersonalbudgets,4 inparticularforpeoplewithcomplexneeds,givingthemgreater
‘choiceandvoice’.Thereis,however,astrongunderstandingthatcertainservices,especially

3.Pooledfundsarewhereeachpartnermakescontributionstoacommonfundtobespentonpooled
functionsoragreedNHSorhealth-relatedcouncilservicesunderthemanagementofahostpartner
organisation.Alignedfundsarewherepartnersalignresources(identifyingtheirowncontributions)to
meetagreedaimsforaparticularservice,withjointlymonitoredspendingandperformancebutseparate
managementof,andaccountabilityfor,NHSandcouncilfundingstreams(AuditCommission2009).
AccordingtotheAuditCommission,pooledfundsarepreferableastheyrequireandprovidegreater
transparency.
4.ThoughitshouldbenotedthattheDepartmentofHealthlauncheditsfirstpilotprogrammefor
IndividualHealthBudgetsin13localauthoritiesin2005.
7 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

emergencyandacutecare,willstillbedeliveredintheconventionalform,asgreater
personalisationwillnotaddvalueorenhancetheseservices,butmightactuallydamage
them.
Thischangeofmoodmightalsobeaffectedbythepositiveevaluationsgiventopilot
programmesrelatingtoself-directedservices,directpaymentsandindividualbudgetsin
socialcareandrecentlyinwelfare-to-work.Theseprogrammesprovedtobeeffectivein
increasingthelevelofsatisfactionwithservicesandimprovingtheoverallhealthand
wellbeingofserviceusers(seeforexampleGlendinningetal 2008).
TheGovernmentisbecomingmoreinterestedintheoptionofintegratingdifferentpublic
services,andinrationalisingspendingonmulti-dimensional,cross-departmentalissuessuch
asclimatechange,personalisationofpublicservicesandreducingobesity.Recentthinkingis
movingtowardstheestablishmentofsingle-issuebudgets,managedbyaleaddepartment
whichshouldthencoordinateactivitiesacrossotherinvolveddepartments(HMGovernment
2009,TheTimes2009).FollowingtherecommendationsoftheDarziReview(Departmentof
Health2008),inearly2009theGovernmentestablishedaministerialworkinggroupon
healthandsocialcareintegration.Thisislookingatpracticalmethodsforandchallengesto
joining-uphealth,socialcareandhousingservices,aswellasthesocialcareanddisability
benefitsystem.Atthesametime,theDepartmentofHealthlaunchedapilotprogrammeof
integratedcarein16localitiesacrossEngland,whichwilltestdifferentapproachesto
integratedcareforgroupsofuserswithcomplexneeds(DepartmentofHealth2009a).
Inordertosuccessfullyintegratehealthandsocialcarebudgets(andpotentiallytoalign
themwithwelfare-to-workandhousingstreamsforcertaingroupsofusers)thereisaneed
forthesystemstofunctiononthebasisofsimilarprinciples.Overthelastfewyears,social
carehasseenadramaticshifttowardsanindividual-centredapproachtocare,while
healthcareisonlyjuststartingtomoveinthatdirection.Thedrivetowardspersonalisationis
atdifferentstagesineachinstitutionandismovingatdifferentspeeds.Thus,different
systemsareatdifferentstagesintermsofadjustingtothenewrealityoftheconceptof
citizenshipinpublicservices.Thereisariskthatthestrongfinancialpressuresfacingthe
publicservicesmayresultinsystemsbeingjoinedupmorehastilythannecessary,andsooner
thaneitherisready.Furthermore,theunderliningphilosophiesofthetwosystemsare
different–freeforallatthepointofuseforhealthcare,means-testingforsocialcare–and
itisimportanttorememberthattherearesomeelementsofeachsystemthatitwillneverbe
possibletointegrate.
Joiningupsocialcareandhealthcarebudgetsisachallengingprocessatthisstage,as
discussionsarestillinprogressabouthowcareshouldbefunded(DepartmentofHealth
2009d).Giventherisingnumberofpeoplewhowillneedcareinthefuture–1.7million
moreadultsthantodayby2026accordingtotheDepartmentofHealth–therightbalance
needstobestruckbetweenthefinancialroleofthestate,andcontributionsfrompatients
andtheirfamilies.InJuly2009,theDepartmentofHealthlaunchedapublicdebateabout
thecreationofaNationalCareService(NCS)whichwouldbringtogetherallaspectsofsocial
care;italsoofferedseveralmodelsoffundinginordertomeetrisingcosts.TheGovernment
iscommittedtoincreaseitsownspendingbyintroducingwiderprovisionoffreepersonal
caretothoseingreatestneed,asannouncedintheQueen’sSpeech,2009.
Thedifficultfinancialsituationrequiresnotonlyagreaterdegreeoffinancialinnovations,
newgovernancearrangementsanddeliveryinstruments,butalsoimprovedassessment
frameworkswhichwouldmakeitpossibletoanalysetheeffectoffinancialinnovationson
thefinal‘product’–theoutcomeofimprovedhealthandwellbeing.Thoughtheremaybe
nodirectsavingsforthesystemintheshortterm,improvedhealthwillmeanlessdemandfor
healthcareandsocialcareservices,potentiallyreducingfuturecosts.Therecentlyintroduced
JointStrategicNeedsAssessmenthasthepotentialtobecomeacomprehensiveassessment
matrixatthelocallevel,asitrequiresacompletepictureofcurrentandfuturehealthand
socialcareneedsatthelocallevel(seeSection4below).
8 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

3.Costsandsavings
Inordertomakethepolicydiscussionmorepractical,itisimportanttogiveatleasta
snapshotanalysisofthescaleofthechallengeintermsoffinancialvalueandthenumberof
users.Thetotalhealthcarebudgetin2008–09wasequalto£101.7billion,whichistwiceas
muchasin2000–01(HMTreasury2009).Duetofinancialpressures,theDepartmentof
Healthwillneedtomakeefficiencysavingsof£2.3billionin2010–11,ontopofthe£8.2
billionefficiencysavingsagreedinthe2008–2011spendingreview(King’sFund2009a).
Thetotalgrosscostofadultsocialcareservicesin2008–09was£16.1billion,a3percent
increaseyear-on-yearinrealterms(NHSInformationCentre2009).Ofthisamount,£9.1
billionwasspentonpeopleagedover65.Expenditureondirectpaymentswas£605million
in2008–09,a31percentincreaseonthepreviousyearinrealterms(ibid),althoughitstill
representsonly3.8percentoftotaladultsocialcarespending.
InMarch2008therewere73,500adultsreceivingdirectpayments,a36percentincreaseon
thepreviousyear(DepartmentofHealth2009b).Intotal,1.8millionpeopleusedadult
socialcareservicesin2007–08,ofwhich1.2millionwereaged65andover(King’sFund
2009b).AccordingtotheAuditCommission,jointexpenditureinthe2007–08financialyear
representedonly3.4percentofoverallspendingonhealthandsocialcareinEngland;by
March2009theamounthadreached£3.9billion5 (AuditCommission2009).
Itisdifficulttofindspecificinformationonhowmuch–ifany–moneymightbesavedby
integratingbudgets.Somespecificexamplesofsavingshavebeenmadebutinmostcases
therehasbeennonotabledifference,asmoneysavedfromavoidingduplicationand
wastagehasoftenbeenspentonsupportingnewgovernancestructuresandadministrative
arrangements,suchaspartnershipsandjointposts.ArecentreportbytheAuditCommission
foundnoevidencethatpublicspendinghadbeensavedinareasthatusedpooledand
alignedbudgetsforprovidinghealthandsocialcareservices.Dataqualityandavailability
wereidentifiedasoneofthekeyreasonsforthisproblem(AuditCommission2009).Itis
thusnecessarytoinitiateaprogrammethatwouldcapturenecessarydataandwouldallow
policymakerstoanalysetherealfinancialeffectofsuchinnovations.Thiswillbeparticularly
importantintheforthcomingperiodoffundingrestraint.

Marketandadministrativechallenges
Therearesignificantchallengesthatneedtobeaddressedinrelationtothemarketof
healthcareprovision.Thereisaneedtodevelopnewsystemsofcommissioningand
infrastructureinorderforthenewsystemofsupporttobeeffective.Thereisalsoaneedfor
themarkettoabsorbtwomodelsofservicesprovision–personalisedandconventional–at
thesametime,assomeserviceswillnotchangeandsomepatientspreferconventional
servicesandwillnottakeupthenewmodelofself-directedsupport.Thecommissioning
processshouldbeadjustedinawaythatallowsconventionalandindividualcommissioning
toco-existeasilyandincentivisesproviderstobeflexibleenoughtomeetdemandforboth
models.
Apartfrommarketreconfiguration,thereisalsoaneedtoreconsiderthefinancialstandards
ofbothservicesinordertounderstandhowtheycanconverge.TheNHS,beinguniversally
freeofcharge,hasmorerigidstandardsandrequirementsintermsofefficiencyofspending
andwhatmoneycanbespenton.Integratinghealthcareandsocialcareintoindividual
budgetsmightrequireco-fundingofunconventionaltreatmentorserviceswhichwouldnot
otherwisebefundedbytheNHS.ItisthusuptoNICE(theNationalInstituteofHealthand
ClinicalExcellence)todefinewhatservicesinthenewsystemshouldorshouldnotbe

5.Thisamount,however,excludessomeotherstatutoryinstrumentsofjoined-upfunding,suchascare
trusts,childrentrustsandgrants.
9 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

fundedfromtheNHSbudget.Combiningsomefreeandsomemeans-testedserviceswillbe
achallengethatbothsystemswillneedtoovercomeiftheyaretoco-existsuccessfully.
Budgetplanningandresourceallocationshouldalsoberevisedinthelightofself-directed
support.Similartodiscussionsalreadytakingplaceinsocialcare,theNHSwillhaveto
considerandapprovestandardsandnormsfordefiningexactbudgetsanddistributingthem
betweenusersandacrossthecountry(thesocialenterpriseInControlcallsitaResource
AllocationSystem–RAS).Itisimportantforpeopletoknowexactlyhowmuchmoneythey
havetomeettheirneedsandthattheyhaveguaranteedminimumstandardsthatwillbemet
regardlessofcosts.Theexperienceofbudgetingforindividualsocialcarebudgetsshouldbe
takenintoaccount.However,asthiswasanongoingexperiencewhichgraduallydeveloped
fromabasictoamoresophisticated,outcome-basedRAS,itwillbedifficulttosimply
replicateit,especiallyashealthcareservicesarecommissionedinadifferentway.

4.Decentralisation
Thefinancialcrisisandtheprospectoffreezingifnotcuttinghealthcareandsocialcarecosts
posedifficultchoicesfordecision-makersatalltiers.Ontheonehand,centralgovernmentis
concernedwiththeoverallcostofservicesandefficiencyofspending.Ontheother,itis
oftenthetaskoflocalauthoritiesandlocalcommissionerstodealwithdifficultchoices–
howtoserveanincreasingnumberof(moreinformedandassertive)clientswithless
funding.Thishasbeenonemajordriverofdiscussionsinexpertandpolicycirclesabout
decentralisationinhealthcare,includingfundingdecisions.
Itisarguedthatlocalorganisationsareinabetterpositiontonegotiatethebestdealsfroma
tightbudgetinordertomeettheneedsofthelocalpopulation(FurnessandGough2009).
Theyarealsoinabetterpositiontomaintaindialoguewiththelocalpopulationabout
changes(andpossiblereductions)toservices.Itfollowsthattheaccountabilityoflocal
commissionerssuchasPrimaryCareTrustsshouldbeincreasedandthatlocalpopulations
shouldhaveagreatersayandinfluenceovertheirdecisionsandchoices.
Thedecentralisationofhealthcareservicesfitswellintoabiggerpicturewherebyvarious
responsibilitiesarebeingdecentralisedfromcentralgovernmenttolocalauthorities.In2000,
localauthoritiesgainedanew‘powerofwellbeing’throughtheLocalGovernmentAct,
whichmeanstheycandoanythingtheyconsiderlikelytopromoteorimprovetheeconomic,
socialorenvironmentalwellbeingoftheirarea(DepartmentfortheEnvironment,Transport
andtheRegions2000).Oneofthecoreobjectivesbehindthecreationofthispowerwasto
encouragelocalinitiativeandtoenhancecollaborationbetweenlocalauthoritiesandother
partnersatthelocallevelasameanstoachievingagreaterqualityoflifefortheir
community.
Morerecently,localauthoritiesandtheirpartners(throughLocalStrategicPartnerships–
LSPs),gainednewpowersanddutiesintheLocalGovernmentandPublicInvolvementin
HealthAct2007(CommunitiesandLocalGovernment2007),suchasthedutytocooperate
intheprocessofdesigningnewSustainableCommunityStrategies(SCS)andimplementing
themthroughLocalAreasAgreements(LAAs).Arangeofregulations,suchasCreating
Strong,SafeandProsperousCommunities(CommunitiesandLocalGovernment2008),
stipulatenewframeworks,responsibilitiesandprocessesthatenablegreatercollaboration
betweenlocalauthoritiesandbodiessuchasFoundationTrusts,HealthTrusts,PCTsand
others.LocalcouncilsplaytheleadingroleinLSPs,buttheaccentisonsharedprioritiesand
actions,whichstrengthensthecapacityoflocalpartnersinimplementingthepowerof
wellbeing.
AmongtheotherinnovationsintheLocalGovernmentandPublicInvolvementinHealthAct
aretheintroductionfrom1April2008oftheJointStrategicNeedsAssessment(JSNA)and
10 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

LocalInvolvementNetworks(LINks).TheJSNAisanewmandatorydutyforallupper-tier
localauthoritiesandPCTs,‘acontinuousprocessthatidentifiesthecurrentandfuturehealth
andwellbeingneedsofalocalpopulation,informingtheprioritiesandtargetssetbyLAAs
andleadingtoagreedcommissioningprioritiesthatwillimproveoutcomesandreducehealth
inequalities’(DepartmentofHealthetal 2008).TheJSNAisthejointresponsibilityofthe
DirectorsofPublicHealth,AdultSocialServicesandChildren’sServices.Itisacrucial
instrumentforincreasingtheefficiencyofcommissioningasitprovidesanup-to-date
pictureofthehealthandwellbeingneedsofthelocalpopulation.TheJSNAinformsthe
decisionsoftheLSPandisanimportantinstrumentforintegratinghealthcareandsocial
careservicesandtheirbudgets(andotherservicessuchaswelfareandhousing)atthelocal
level.
TheLocalInvolvementNetworks(LINks)establishedineverylocalityareresponsiblefor
involvinglocalpopulationinshapinglocalsocialandhealthcareservices.SinceLSPsand
theirleadlocalauthoritiesareboundbythe‘dutytoengage’toworkcloselywith
representativesofthethirdsector,thebusinesscommunityandthegeneralpublicin
definingprioritiesandimplementingspecificplans,theLINkswillstrengthenthe
accountabilityofservices’providers,betheylocalauthoritiesorPCTs.
Itisimportanttobearinmindthatanycallsforgreaterdecentralisationandlocalismin
publicservicesdeliveryarelikelytohaveasecond–negative–side.Publicopinionissuch
thatdespitethefactthatlocalinnovationsandflexibilityareconsideredasapositivething,
anydivergenceinservicesprovisionfromlocalitytolocalityisoftenthoughttobe
unacceptableandreferredtoasanunfair‘postcodelottery’.Hence,anypolicythinking
behindchangingthelevelsofresponsibilityandaccountabilitybetweencentralandlocal
tiersshouldseriouslyconsidermodelsoflocalengagementwiththepublicandwaysof
representinglocaldivergencesothatithasamorepositivethannegativecharacter.

5.Prevention
PreventionisbecominganespeciallycrucialelementoftheUK’shealthsystemduetothe
challengesidentifiedabove:changingdemography;agrowingnumberofmoreassertive
serviceusers;therisingcostsofhealthcareandsocialcare;andsqueezedpublicfunding.
Traditionally,therearetwotypesofpreventivemeasures:
•Primary,forthosewhohavehadnoprevioushistoryofadiseasebuthavesomerisk
ofacquiringitinthefuture
•Secondary,forpeoplewhohavealreadysufferedfromaninstanceofthediseaseand
requirefurtheradviceandinterventiontopreventthemfromfurtherproblems.
Ithasbeennotedthatthereisnotalwaysenoughcoordinationbetweenprimaryand
secondarypreventivecare,whichhasanegativeimpactonfinalhealthoutcomes(National
AuditOffice2009).
Thereisaquestionastowhetherintegratingbudgetsfromdifferentserviceswillenable
strongerpreventionmeasuresthatwouldtargetawidergroupofpeople.Riskassessment
andscreeningisbelievedtobeacrucialelementofpreventivemeasures.However,quite
oftentheseproceduresaremadeforasingledisease,suchascardio-vasculardiseasesor
cancer.Expertsargueforamoreholisticandcomplexapproachwherebylifetimeriskis
assessedintermsofarangeofdiseases(Furness2008).Thereisalsoaquestionasto
whetherinterventionsshouldfollowimmediatelyafterinitiallifestyleandhealthrisksare
identified(especiallyformentalhealth).Currently,thereareonly‘light’servicesofferedto
peoplewithpotentialhealthproblemsintheformofliteratureandadviceonhowtochange
theirlifestyle.Thismaynotbeenough,andsomeexpertsarguethatmore‘invasive’primary
11 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

interventionsarerequired(ibid).Thisdemandsagreaterintegrationofprimarycareproviders
withotherareasofhealthcare.
Coordinationisalsorequiredtobringpeoplewith‘manageable’healthconditionsbackto
work.TherearealreadyspecificprogrammesrunbytheDepartmentforWorkandPensions
thathavethisaim.However,notallprimaryhealthcareinstitutionsdirecttheirpatients
towardstheseprogrammes(NationalAuditOffice2009).Therearesomepilots,likethe
RighttoControlprogrammeinitiatedbytheDepartmentforWorkandPensionsineight
localities,whicharelookingtotesttheeffectivenessofintegratingsocialcareandwelfare-
to-workservicesandfundingforpeoplewithdisabilities(Ben-GalimandMcNeill2009).The
possibilityofintegratinghealthcareservicesintothesepilotsshouldbeexploredtosee
whetherthismightmakeanevengreatercontributiontothefinalhealthandwellbeing
outcomesofpeoplewithdisabilities.
Primarycareinstitutions(PCTsandGPsurgeries)arebelievedtobethebestplacefor
identifyingpeopleatriskandofferingfirstinterventions.However,thereissomeevidence
thatforsomeillnesses,GPsarenotalwaysqualifiedenoughtoidentifytheproblemand
referthepatienttospecialistcareatearlierstagesofthedisease(NationalAuditOffice
2009),whichultimatelyresultsinhigherhealthcarecosts.6 Thereisalsoachallengeposedby
peoplewhohaveagreaterriskofcertainillnessesduetotheirlifestylebutwhorarelyor
neveraskformedicalhelp.Inthesecases,welfareandsocialservicesmighthelp,asthey
haveaccesstoawidernetworkofpeoplewhoarevulnerableandareingreaterdangerof
becomingill.Itisthusnotenoughtointegratehealthcareandsocialcareservicesinorderto
increasetheefficiencyofpreventivemeasures,astheseservicesmostlydealwithpeoplewho
arealreadyawareoftheirproblems.Onlysecondarypreventivemeasureswillbemore
efficientinthesecases.Therolesofwelfareandsocialserviceagenciesarecrucialin
enhancingprimarypreventativemeasuresamongdisadvantagedgroupsofthepopulation
thataredifficulttotarget.
PreventivecareisattheheartoftheproposedNationalCareService(NCS).Both
Governmentandexpertsarearguingthatshiftingshrinkingfundingtowardspreventionwill
offersubstantialsavingsforboththeNHSandNCSinthelongerterm.Forexample,inthe
recentlypublishedGreenPaperonSocialCare(DepartmentofHealth2009d)thereisa
greateremphasisonpreventionthanontreatmentforallgroupsofclients,especiallyfor
peoplewithlong-termconditionsanddisabilitiesandforolderpeople,whichpotentially
couldsavemoneyforbothsystemsatlaterstagesofcare.Newapproachestocarelikeself-
directionandpersonalisationarealsocontributingtopreventivecare.Theevidencefromthe
DepartmentofHealthsuggeststhatimprovingself-carecoulddecreasethelengthofstayin
hospitalsformentalhealthpatients,reduceA&Evisitsforasthmapatientsandhalvethe
numberofsickdaysforpeoplewitharthritis,whichwouldallcontributetobringingdown
thecostofthehealthcaresystem.
Nonetheless,manyquestionsremaininrelationtoassessingthecostsandbenefitsof
specificpreventivemeasures,especiallyinsocialcare.NICEisalreadyassessingthe
effectivenessofpreventivemeasuresfortheNHS,andtheGovernmentarguesthatthereisa
needforasimilarbodytobecreatedinthesocialcaresector.

6.Forexample,modellingbytheNationalAuditOfficesuggeststhatiftheshareofpatientsdiagnosed
withrheumatoidarthritiswithinthefirstthreemonthsofthediseaseincreasedfrom10to20percent
thetreatmentcostswouldriseby£11millioninthefirstfiveyearsbuttheoverallproductivitysavingfor
theeconomywouldbe£31million(NationalAuditOffice2009)
12 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

6.Therationaleforintegratingbudgets
Itisimportanttounderlinethatintegratingservicesandbudgetsisnotalwaysappropriate.
Integrationcanbringbenefitsforhealthandsocialcare–andindeedforwelfare-to-work
andhousingservices–whenitiscarefullydesignedandappropriatetothecontext.Itshould
not,however,betoutedastheanswertoeverythingandrolledoutwithoutthought.
Differentsystemsandservicesarebasedondifferentprinciples,anditwillnotalwaysbe
possibletointegratesystemswithoutcompromisingthefundamentalrightsofusersand/or
thequalityofservices.Furthermore,evenwhereserviceshavemanysimilarities,theymay
stillservedifferentpopulationgroups(someareuniversal,othersareveryselective).Hence,
whilecrucialinmanyaspectsofpublicservicesplanninganddelivery,users’voiceandchoice
arenotalwayspre-determinantsofsuccess.Somecomponentsofhealthcare,welfare-to-
workand(lessso)socialcaremustcontinuetofunctionasstand-aloneservicestoensure
thebestoutcomesandvalueformoney.
Therearetwodriversforintegratinghealthandsocialcarebudgetsinthecurrentmodelof
servicesprovision(seeFigure1),whichwesummarisebelow.

Figure1:Twodrivers
ofintegratinghealth
andsocialcare
servicesandbudgets

Enhancedcitizenship
Enhancedcitizenshipinpublicservicesmeansthatcitizens,aswellasfrontlineprofessionals,
areempoweredinplanninganddeliveringindividually-tailoredpublicservices.Thisisviaa
combinationofself-direction,personalisation,co-productionandthenewcitizenshipmodel
inpublicservices.Theaimistoachievebetteroutcomesbystrengtheningthecommitment
ofeachofustoeachotherandtothewholecommunity(Duffyetal 2009).
Inpractice,thismeansextendingtheprinciplesofself-directedsupportfromsocialcareto
someareasofhealthcare,housingandwelfare-to-work,leavingoutthoseareasthatare
impossibletopersonalisewithoutunderminingtheirimpactoroutcomes(forexample,
emergencyandinvasivetreatmentinhealthcare).Itwillinvolveintegratingserviceprovision
andfunding(throughindividualbudgets,whichcombineseveralfundingstreamsofdifferent
servicesforthebenefitoftheuser),aswellasintegratingoperationalandadministrative
systems.
13 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

Again,itisimportanttounderlinethatnotallservicesarefitforintegrationand/or
personalisation,andthatitisnotacceptablesimplytodirectlytranslateself-directionfrom
onespheretoanother.Whilethegeneralprinciplesmaybemoreuniversallyapplicable,each
sectorwillrequireitsowninstruments,standardsandbudgetingforself-directedsupport.

Financialandadministrativeefficiency
Theseconddriverisfinancialandadministrativeefficiency,whichinthelastfewyearshas
becameevenmoreimportantduetobudgetaryconstraintsandthepressureforsavings.
Thereisawidespreadunderstandingthatthe‘financialbonanza’periodinthepublicservices
isoverandthatausteritywillbethewatchwordforsometime.Thereisthusagrowing
numberofpolicyprovisions(suchassingleissuebudgets)andpracticalstepsforpoolingor
atleastaligningthebudgetsofdifferentservicesproviders,whichallaimtoprovidebetter
qualityserviceswithlessmoney.Anotherbenefitofthisinnovationisthatitmakesservices
lessconfusingandmorecentredonspecificclientgroups.

Combiningindividual-andsystem-centredintegration
Thesetwodrivershavetheirowndistinctivenaturesandobjectives.Enhancedcitizenshipis
centredontheindividual,theirneedsandaspirations.Efficiencyiscentredonthesystemof
servicesprovision.Wesuggestthatthebestwaytointegratebudgetsistocombinethese
twoinnovationstreams–individual-centredandsystem-centredintegration.Individual-
centredintegrationrequiresfrontlineexpertisetoplayaleadingrolewhileengaginghigher
tiersofgovernanceinordertoensurethesystemicchangeindelivery.Insystem-centred
integrationcentralgovernmentneedstoplayakeyrolebutengagelocalinstitutionsand
frontlineprofessionalsaspartnersinallstages.
Thefinancialefficiencyofeitherofthesestreamsofintegrationisstillunderquestion.There
isnostrongevidencethatself-directedsupportinsocialcareandwelfarepolicy(via
individualandpersonalbudgetsanddirectpayments)savesagreatdealofmoney,though
therearecasesofsavingsforspecificgroupsofclients(seeforexampleGlendinningetal
2008orDuffyetal 2009).Oneofthekeyargumentsisthatitisarelativelynewpolicy
initiative,affectingarelativelysmallnumberofserviceusersandinvolvingasmallshareof
totalservicecosts.Thusthereisnosufficientdatasettomeasurethefinancialgains
effectively.Ontheotherhand,thereisalreadysomeevidencethatintegrationdoesnotcost
anymoremoneyandthatitleadstopeopleexpressingmoresatisfactionwiththeservices
theyreceive,thankstoincreasedengagementandtherighttocontrol.Also,self-directed
supportoftenhasastronglypreventivenature.
Aswithmostpreventivemeasures,itisachallengetoattributeanychangesdirectlytothe
originalintervention,whichmakesitdifficulttomeasurethedirecteffectontheshort-term
costsofeitherhealthcareorsocialcaresystems.Overthelongerterm,however,theeffectis
moredefined,asdemonstratedabove(forexample,theDepartmentofHealthregistereda
reductioninthenumberofhospitaladmissionsandinA&Eusageamongpeoplewhouse
self-directedservicesandtheNationalAuditOfficecalculatedproductivitygainsforthe
economythroughbetterdiagnosisandpreventivemeasuresintreatingrheumatoidarthritis).
Pooledandalignedbudgetsaremore‘administrative’than‘human’innature,andthese
typesoffinancialinnovationinhealthandsocialcareservicesareeasiertoimplementand
thenassessintermsoftheireffectivenessinsavingpublicmoney.Arecentreportfromthe
AuditCommissionquestionsthelinkbetweenpooling/aligningbudgetsandreducedcosts
ofservices,andnotesthatthereissofarverylittledataregardingtheimpactofsuch
practicesonfinalhealthoutcomes(AuditCommission2009).However,webelievethatthis
approachhasmorepotentialforcuttingcosts,asitdealswith‘groupneeds’ratherthan
individualneeds.Groupneedsareeasiertomakemorerationalandcost-effectivethrough
improvedcommissioningandbyshiftingtheemphasisfromtreatmenttopreventive
measures.
14 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

Democraticcontrol,whichisessentialinthenewmodelofpublicservicesdelivery,isless
clearinsystem-centredintegrationthaninindividual-centredintegration.Poolingand
aligningfundingstreamsforserviceswithdifferentdegreesofaccountabilitycouldbe
managedby‘non-democratic’institutions(suchasPCTs)whichcouldlimitcitizens’
controloverthedesignandimplementationofservices,whichareusuallythe
responsibilityoflocalcouncils.Thereisthusaneedfornewstrengthenedmodelsof
accountability(throughsupervisoryboardsornetworkssimilartoLINks)andforthe
safeguardingofnewintegratedserviceswhichwillnotonlybeefficientintermsofusing
publicfunding,butwillalsobetransparentandunderstandableforthegeneralpublic.
Therearealreadyseveralpracticalstepsinthisdirectionofferedbythe2008NHSreview
andtheLocalGovernmentandPublicInvolvementinHealthAct2007(seeSection4
above).
Thereisalsoatensionbetweenthepersonalisationagenda(introducingindividual
budgets)andpooling/aligningbudgets.Frontlinestaffinthepilotsofindividualbudgets
forsocialcarenoticedthatinmanycasesthisinnovationiscounter-productive(Glasby
2008).Asindividualbudgetsareoftenofferedtopeoplewithcomplexhealthandsocial
careneeds,whichareoftenprovidedbyPCTsandonthebasisofinter-agency
collaboration,separatingthesocialcaresegmentfromtheoverallpackageinorderto
‘wrap’itintotheindividualbudgetcausedconfusionanddifficulties.Peopledonot
understandwhytheycannotreceiveanintegratedindividualbudgetfortheentire
packageandwhytheyshouldchangealreadyestablishedpracticesandexistingproviders.
Bearinginmindtheselimitationsofthetwoapproachestointegratingservices–person-
centredandsystem-centred–andsomechallengesoftheirco-existence,webelievethat
thebestwayforwardistocombinethetwo.Themostrationalapproachwouldbetouse
individual-centredinstrumentsintheareasthatarepossibletopersonaliseinorderto
respondtothecomplexneedsofspecificgroupsofusersthatstretchacrossthesilosof
healthcare,socialcare,welfare-to-workandhousing(forexample,peoplewithdisabilities
andolderpeople).ThisapproachhasalreadybeenemployedbytheGovernmentinits
variouspilotprojects.
Integrationofback-officeservices,procurementandotheroperationalelementsneedsto
beguidedbyinstitutionalexpediencyandvalueformoneywhereitisimpossibletousea
personalisedapproach.However,thereisaneedtocoordinatedifferentpartnersthatare
deliveringsimilarservicesorworkinginthegeographicalproximity.Anotherchallengeis
toensurethatfutureattemptsatintegrationbeginwitharealisticmeasurementofthe
currentsituationandanestimationoftheprojectedcostsandimpacts(particularlyon
thehealthandwellbeingofthelocalpopulation),againstwhichitwillbepossibleto
monitorandevaluatesuccessingreaterdetail.
Inthismodel,differentsegmentsofservicesandtheirmarketswillbeaffectedeitherby
person-centredorsystem-centredfinancialinnovations,whichshouldcombinetobring
improvedoveralloutcomes.Inthiscaseitwillbepossibletoreducecosts,asthefinancial
climatedictates,andatthesametimetoenhancepersonalsatisfactionbygivingcitizens
astrongerroleintheplanningandprovisionofservicesthatimprovetheirhealthand
enhancetheirwellbeing.However,inordertoachievesuccess,thereneedstobe
understandingandpracticalsupportforthisprocessfromthehighestlevelsof
government.Otherwise,thereisariskthatcombininglocalinitiativeswithpilotsand
instrumentsdesignedatthenationallevelcouldbecomecounter-productiveandusers
andfrontlineprofessionalscouldbediscouragedfromimplementingsuchmodelsoutof
fearofthemanyproblemsandconfusionthatmightlieahead.
15 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

7.Relevantpracticesandpilots
Therearefewpracticalexamplesofintegratinghealthcareandsocialcarebudgetsand
services.Therearemanyexamplesofadministrativemeasureslikepoolingandaligning
budgets,buttheydonotgoasdeepinjoiningupservicesandtheirfundingasintegration
implies.Belowaresomeexamplesofintegratedcarepilots,andalsopilotsrelatedtoself-
directedandpersonalisedsupportinsocialcareandwelfare-to-work,whichmightbe
relevantforourdebate.
Itisimportanttolookforinspirationandlessonsnotonlyinothersectorsofpublicservices,
butalsointheUK’sdevolvedadministrations.Devolutionofpowerstothegovernmentsof
Scotland,WalesandNorthernIrelandcreatedopportunitiesfordifferentapproachesto
planninganddeliveryofthesamerangeofservices.Potentially,thiscouldeasetheprocess
oflearningtheeffectsofdifferentmodelsandcouldalsoofferopportunitiesforcross-
fertilisationofapproachesandpractices.Bothpositiveandnegativeexperiencesare
importantinthisregard.

Examples
ConnectedCare: apilotprogrammeforintegratinghealth,socialcareandhousingservicesin
themostdeprivedcommunities.Community-led,itwilltestnewwaysofcommunity
engagementandcommissioningledbythecommunity.Itiscurrentlyinthefirststage,an
auditoflocalneedsandaspirations;thesecondstagewilldesignintegratedservices
correspondingtothecommunity’sneeds.TheTurningPoint:ConnectedCareCentreof
ExcellencechampionsthedeliveryofConnectedCareinEnglandandWales.
RighttoControl: apilotprogrammedesignedbytheDepartmentforWorkandPensionsfor
eightlocalauthoritiesinordertotestthepossibilitiesofintegratingsocialcareandwelfare-
to-workservicesforpeoplewithdisabilities.Itwaslaunchedin2008anditistooearlyfor
anyconclusionsregardingitsefficiency.
InControl:launchedin2003,thiswasthefirstprogrammetodeveloptheconceptofself-
directedsupportinsocialcare.Ithasalreadyledtosomeconcreteresults,mostlypositive,as
highlightedinanevaluationbyYorkUniversity.InControlisnowanationalcharitywhich
extendsself-directionintootherpublicservices,suchashealthcareandwelfare-to-work.
StayinginControl: apilotjointlylaunchedinspring2009bytheDepartmentofHealth,
CSIP(CareServicesImprovementPartnership)andInControltoextendself-directionand
personalisationpracticesfromsocialcaretohealthcare.Itisbeingtestedin34local
authoritiesandthefirstresultsarenotexpecteduntil2010.
ProgrammeofIntegratedCarePilots: atwo-yearinitiativelaunchedbytheDepartmentof
Healthin16locallocalitiesin2009.Itistestingmodelsofintegratingdifferentcare
elementsinordertoachieveseamlessandeffectiveservicesprovisionfordifferentgroupsof
userswithmultipleneeds(forexample,elderly,disabled,peoplewithdiabetes,substance
abusers).
PersonalHealthBudgets: pilotsbytheDepartmentofHealthin13localitiesin2005–2007
toseewhetheritispossibletoextendthismodelofservicesprovisionfromsocialcareto
healthcare.TheresultsofthesepilotswerepositiveandtheDepartmentofHealthhassince
launchedmorewidespreadpilotsofindividualbudgets(seebelow).
IndividualHealthBudgets: pilotslaunchedbytheDepartmentofHealthinSeptember2009
in20localities(outof70thatdeclaredtheirinitialinteresttoparticipateinthepilot).Thisis
atwo-yearprogrammewhichaimstodevelopmodelsandinstrumentsfordefiningand
implementingindividualhealthbudgetsforpeoplewithlong-termdisabilities.
IndependentLivingFund(ILF): thefirst‘cashforcare’scheme,introducedin1988,
providingmoneyforthecareofseriouslydisabledpeoplelivingathome.Currentlythereare
16 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

somechallengesofintegratingthisfundingstreamwithotherstreamsfordisabledpeople
(forexamplewelfare-to-work)andtheDepartmentofHealthisconsideringhowILFfitswith
theindividualbudgetmodel(HenwoodandHudson2007).

8.Conclusions
Themodern,individualisticworldrequiresmorepersonalpublicservices.Atthesametime,
theeconomiccrisismeansthatlesspublic(andprivate)fundingisavailableformore
sophisticated,technology-intensiveservices.Aspublicspendingwillbefacingsevere
constraintsinthecomingyears,itmustdevelopandimplementinnovativepolicyand
financialinstrumentswhichcancutcostsbutatthesametimeprovidehigh-qualityservices
toallthosewhoneedthem.
Ourbriefanalysisheredemonstratesthatintegratingdifferentservicesandfundingstreams
mightbethewaytoaddressthisdouble-facedchallenge.However,decision-makersshould
notchoosebetweenindividual-centredandsystem-centredintegration.Neithershouldthey
runthesetwotypesoffinancialandorganisationalinnovationsinparallelwithoutdueregard
totheiroverlappingandsometimescounter-productiveimpactoneachother.Understanding
thenatureoflocalserviceintegrationinnovationsatthecentrallevelisapre-conditionfor
theirsuccessfulimplementationandsustainabilityafterothernational-drivenreformsrelated
toeitherfinancialefficiencyorpersonalisationcomeintoforce.Wearguethatathorough
combinationofindividual-centredandsystem-centredintegrationwillbethebestwayto
tacklethelackofresourcesandtheneedtorespondtomoreindividualandcomplexneeds.
Therearestillmanyquestionsintermsofthefinancialefficiencyofintegration.Thereare
veryfewevaluationsofthismatter,andthosethatdoexisthavenotdemonstratedthat
integrationbringsanysignificantsavingsforeitherhealthcareorsocialcare(seeforexample
AuditCommission2009).Ontheotherhand,thereisalsonoindicationthatitincreases
costs.Thelackofaproperdatasystemwasidentifiedbymanyexpertsandpolicymakersas
oneofthecoreobstaclestoanyproperassessmentoffinancialimpact,andifthisis
addressedinthenearfuturewebelieveitwillbepossibletodemonstratethepositiveeffect
ofintegrationonpublicspending.Bearinginmindtheneedsforsavingsinthenearfuture,
makingmechanicalcutsacrossallpublicservices(forexample10percent)mightbe
dangerousasitisdoesnottakeintoaccounttherespectivesignificanceofparticular
streams.Itmightwellbepossiblethatcuttingfundinginoneareabyonly5percentornot
atall,butchangingitswayofuse(forexamplefundingmorepreventivemeasures),might
save10oreven20percentofspendinginanotherelementofthesystem.Thisisan
importantissueforfurtheranalysis.
Asacornerstoneofmodernhealthcareandsocialcaresystems,preventionisacrucial
elementforaddressingproblemsatearlierstages.Itmightleadtoashort-termincreasein
NHSorsocialcarebudgets,butitwillbringgreaterlong-termgainsforthenational
economy,forexamplethroughahealthierandmoreproductiveworkforce.
Thereisasignificantopportunityforfurtherdiscussionamongpractitionersand
policymakers,bringingtogetherseveralissuesthatarealreadyoccurringinseparatepartsof
thesystem.Furtherresearchintothefinancialimplicationsofintegratingservicesand
increasingtheshareofpreventivecareinNHSiscrucialindefiningthesuccessofthe
currentpathofreforms–towardspersonalisationandgreaterefficiencyofpublicservices.
17 ippr|IntegratingHealthandSocialCareBudgets:Acasefordebate

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