Integration of Primary and Community Care (Committee Report)

Baroness Finlay of Llandaff Excerpts

Thursday 9th May 2024 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare and update my interests as listed in our report, as I now chair the Bevan Commission in Wales. It was a pleasure to be on this committee, so ably chaired by the noble Baroness, Lady Pitkeathley. She kept our focus on the topic at hand and worked extremely hard when there were changes of personnel in the clerical staff supporting our committee.

I came to this very important inquiry with experience of having set up hospice services from scratch, where nurses and care assistants needed upskilling and where bringing everybody together, including clerical and reception staff, for open education sessions resulted in them being able to outreach into community services. We established integrated working. Each person knew what the other one could do, and people worked to the top of their game.

As a committee, we were very keen to explore ways to transform the patient experience and decrease demand on health and social care services. We were acutely aware that we should not incur expenditure nor suggest major reorganisation but should reduce the waste from inefficient practices, and that much can be done by different attitudes and approaches.

We were acutely aware that patients want continuity of care. They often feel pushed from pillar to post, not sure whom to contact or even how to contact someone whom they have seen previously. If they get past an answerphone, they find that they are repeating their story time and again, uncertain about who does what and endlessly waiting for the next appointment along a whole chain that feels like a disjointed slow relay. Our suggestion to put health and social care providers together as much as possible, sharing ongoing training, sharing premises and with access to each other’s records, is really at the heart of patients’ experience of integration.

Yet the government response is deeply disappointing. Rather than welcoming our recommendations to provide additional strengths to their plans towards integration—which are outlined in their response—it reads as if the Government are saying, “We are doing it all already”. Yet, time and again, we heard from services about how disjointed they are. We heard about the changes that need to happen to bring health and social care together under one roof in premises fit for purpose, and we heard how disjointed IT systems are. The data held in the different record systems should be viewed as the patient data—it is about them—yet there seemed to be endless blocks to bringing staff and systems together.

We had hoped the Government would welcome our suggestions for patient data to be shared usefully and safely; for the multidisciplinary team to meet together and plan care; for joint education that would upskill social care to remove the risk-averse barriers to interventions that so often result in patients being put in an ambulance from home or a care home and sent to an already overcrowded emergency department for problems such as a blocked catheter or blocked feeding tube to be sorted out, when it could happen so much more easily if staff were upskilled and the patient would not then need to be moved. Many of the bureaucratic blocks could be overcome by honouring contracts that have all staff working together with common aims and contractual changes that reward work done and outcomes, with meaningless bureaucracy stripped out.

We repeatedly heard how patients cannot get the holistic care they need because staff are working in silos, often overseen by risk-averse attitudes from their managers; they do not feel able to do what needs to be done but revert repeatedly to a view of limited job responsibility. By staff working together under the same roof, as we suggested, for evolving general practices and primary care, integrating with local social care providers and the voluntary sector, the culture of care provision could be improved and better monitored to provide far better health outcomes in the longer term, particularly for frail and vulnerable people, for whom stability of place and of staff is especially important.

The Hewitt Review, published in 2023, found that culture, leadership and behaviours matter far more than structures. We wanted to break down the barriers in contracts and in behaviours, but the Government’s response seems to pull back from supporting our recommendations to focus on broad policies that were written recently, rather than address the need to build on them to create the crucial interpersonal relationships that determine good care. We felt disappointment in the Government’s response because it did not build on what they already are putting in place and encourage further integration, and it seemed almost to dismiss some of our suggestions by saying what they were doing but without welcoming our recommendations.