Integrating Health and Social Care: State or Market?

1. Medical and nursing care have been separated from social care by deliberate design since the creation of the NHS. This is true with regard to the institutional and policy frameworks and also with regard to how care is provided in practice. 2. This divide, even if once justified, is now entirely artificial. People spend far less time in hospital than used to be the case and four million people over the age of 65 have a life-limiting illness. In such circumstances, medical, nursing and personal care should be combined in different ways in a range of institutional settings. 3. Technology is also changing medical and nursing care. Smartphones, for example, can be used to monitor medical conditions whilst assessment takes place remotely. Phones can be used to monitor glucose levels in diabetics and to control insulin uptake more precisely. This is also contributing to the breakdown in the divide between medical, nursing and personal care and the institutional settings in which they take place. 4. There have been growing calls for the greater integration of health and social care. Such proposals invariably involve a significant role for the state in integration, ranging from the current government’s policy of bringing the functions under one ministry to Labour Party proposals for a National Care Service. 5. The National Health Service is already the fifth largest employer in the world with 1.4 million people and the third largest employer in the world that is not an army. The social care sector employs 1.6 million people. An integrated national health and care service would be the largest employer in the world. Bringing social care within the orbit of government planning and finance would lead to the creation of a centrally planned service without precedent in the Western world. 6. Dis-satisfaction with the current regime arises partly because of the totally different policy frameworks for health and social care established at the creation of the NHS. On the one hand, healthcare is largely centrally planned and delivered. On the other hand, social care, personal care and some nursing care is delivered and organised by a huge range of organisations including local authorities, hospital trusts, profit-making companies, social enterprises, non-profit-making companies, voluntary organisations and religious groups. It is very difficult to achieve integration of health and social care in these circumstances. 7. Competition and markets are the best way to discover how to integrate health and social care. Such integration could be expected to happen in different ways in different contexts and through different providers. In order to achieve meaningful integration, we should make the health sector more like the social care sector so that there is more pluralism in provision and financing. This would also move health provision closer to the models that exist in continental Europe. Providers could then compete on the basis of how they integrated different aspects of care. 8. Competition and markets are also necessary to facilitate pluralism in the health and social care sectors. Different people have different preferences for different types of delivery (for example, whether home or hospital based, whether to focus on care or medical treatment, the extent to which technology is desired, and so on). Also, ethical views on the provision of care differ. Given that medical, nursing, social and personal care will be such an important part of the lives of a large proportion of people, it is vital that people are able to make active choices about how different forms of care are provided and combined.