Improving the integration of health and social care in England during the last decade: Why prioritised? what effort? what obstacles? what achievement? what opportunity costs? what promise?

The priority to ‘integrating' social into a broader health policy increased from 1997 in response to failures of agencies and field staff to coordinate and maximise overall benefits. How publicly commissioned/managed social care contributed to health policy goals became a principal performance criterion used to allocate important rewards and sanctions to local authorities, the local agencies responsible for performance of their social care systems. First the paper uses evidence from a before-after study to describe the benefit mix prior to the impact of the new prioritisation. It showed remarkable improvements in outcomes of value in their own right and clear relationships between services, risk factors and outcomes, but also failures of ‘integration' at field and agency levels suggesting under-performance for user groups. Secondly it considers Department of Health integration policies and models subsequently developed in their context of broader changes in health policy. Evidence suggests that earlier targeting of integration effort to reflect the likely costs and a wider range of benefits for user sub-groups and might have achieved more for patients and others. Thirdly it describes evidence about barriers that implementation encountered particularly in commissioning and providing agencies at management and field levels. Fourthly, it considers evidence about policy effects for structures, processes and outcomes. Fifthly, it considers evidence suggesting high opportunity costs ignored in health policy discourse driven by government, contrasting particularly analysis in the internationally innovative and sophisticated literature on the relationship between funding mechanisms, criteria for the evaluation of funding mechanisms and policy means and ends.