Introduction

Health and social care services in England are delivered by two distinct systems. At the establishment of the National Health Service (NHS) in 1948, hospitals provided free care for the sick, and those needing ‘care and attention’ were placed in residential homes provided by local authorities, which could charge for services. Concerns about the division between the two systems and disjointed care for patients have been raised repeatedly over the years and consecutive generations of policy makers have introduced reorganisations and other policy initiatives in attempts to address this fragmentation with little effect.

Compounding the issue of fragmentation between the systems, the population of England is ageing rapidly. As a result, the rising proportion of older people has significant consequences for the health and social care systems. In 2010 around 10 million people were over 65 years old; by 2050 this is set to have nearly doubled to around 19 million. The number of very elderly people over the age of 80 is growing at a greater pace; from around three million in 2010, the number is set to increase to around eight million by 2050 (Cracknell, 2010). Not only is the proportion of older people growing, but the cost of care for each older individual is also rising (Ham and Walsh, 2013). A side-effect of the ageing demographic is that increasing numbers of people have longterm health conditions (Ham and Walsh, 2013). The number of elective and non-elective hospital admissions for older people is increasing and projections suggest that in the future a high proportion of older people will be living on their own and will require formal care (Ham and Walsh, 2013).

This chapter reviews the case for integration in the current financial and policy context in England. It examines some of the reasons why so little progress has been made to date, despite periodic policy initiatives to promote integration. It discusses some of the most prominent themes emerging from the recent literature, identifying a number of structural and cultural issues that have prevented integration from occurring. Finally, it offers some recommendations for taking integration forward, based on this discussion.

The case for integration

One answer put forward to address the challenge of fragmented systems is integration across health and social care. Integration is a broad concept and has been used in a variety of different contexts.