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Integrated care – from whose perspective?

Integrated care is heralded as the way forward for health and social care services facing the increasing demands of populations who are living longer, and where increasing numbers of people are living with complex conditions. Mary Twomey, programme director for health and social care at the Open University, argues that in order to succeed, delivering integrated services involves challenging individual as well as organisational practice.

To suggest that the integration of health and social care provision is necessary is to risk understatement, particularly from the perspective of people with complex needs. Evidence from organisations such as National Voices reveals a picture of care that is fragmented, un-coordinated and often frustrating. Contrast this with evidence from projects where integrated care works well, and the argument for integrated services, at least from the perspective of users of services, becomes clear.

And the numbers of people with complex needs are increasing, of course. Over the next 20 years, the number of people aged over-85 is expected to increase by over 100%, and the number of people living with multiple complex conditions is set to rise, a trajectory that requires a very different approach to the provision of healthcare, to one of acute hospitals providing in-patient care to large numbers of people with long-term conditions. If health services are to be sustainable, it’s clear that admission and re-admission rates need to fall, and services need to be delivered both effectively, in terms of outcomes for those who use them, and efficiently.

To say that providing effective and efficient integrated services is a challenge, however, is also to risk understating the case. As Richard Humphries of the King’s Fund says on his blog, the most effective use of the Better Care Fund requires “collaboration across the whole system of health, care and support, engaging fully with all NHS, local authority and third sector partners”, and “a reduction in hospital activity and income”.¹ This, he says, is “big, risky and hard to do” in terms of the tough choices required around resource allocation.

What’s also big, potentially risky and certainly hard to do is changing the day-to-day experience of those in receipt of care. The document that describes the vision of the National Collaboration for Integrated Care and Support identifies key principles, which to some extent describe the structures and working relationships necessary to achieve this vision.² What it doesn’t do, however, is to pin down the fundamental problem that needs to be addressed for integrated services to work routinely and across the board, and that is the lack of a common approach to care by those who are actually delivering that care, the people on the ground.

That a problem exists is acknowledged by frequent references to the need for ‘culture change’, both at an organisational and an individual level. It is this culture change that is implicit in the King’s Fund’s call for the emergence of services to be ‘bottom-up’ as well as at organisational level.³ Unfortunately, though, it’s the organisational aspects of change that are easier to define: to incorporate into a vision and plan, and to subsequently evaluate. There is a danger that this is where the focus remains.

Changing structures at national or at local level will not on their own deliver integrated care, or at least not if this is where efforts stop, without changing the starting points of those who deliver care services to those who use them – the community nurses, personal care assistants, social workers, care managers, occupational therapists and the myriad of other professionals who traipse through the houses of people with complex needs and add, unintentionally, to the confusion.

Patient wishes vs patient outcomes?

Primary care has been identified as the key player in integrated services and the health service of the future, but primary care, for all its links with public health and the health of communities, is still strongly associated with meeting (clinical) needs, and doing so in the best interests of the patient. Acting in the best interests of patients is deeply rooted in the working practices of NHS staff, and ironically means that sometimes the expressed wishes of those patients are difficult to hear when these run counter to what is considered to be good care.

Why is this an issue for integrated care? It’s an issue because there is a risk that those actually delivering care to individuals may be talking different languages, or at least may be uncomfortable with or unable to hear a different perspective.

Differences in underlying values between social workers and clinicians

Social workers, for example, see their underlying values as respect for persons and promoting self-determination. They see themselves as autonomous practitioners, an approach which was given the seal of approval by the Department of Health in 2011⁴ in the ‘Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers’ command paper. From my own experience as a community nurse in the 1990s, I can remember situations when these two different approaches – working in the best interest of patients and promoting the rights of the individuals to live as they wished – led to stalemate, and these stalemates did nothing to reduce the need for future interventions.

Without a careful exploration of the different cultures that exist on the ground in the services that we want to work together, therefore, there is a real risk integrated approaches will fail at the coal face.

That this continues to be an issue (my experience is somewhat dated, after all) was evident in an innovative series of workshops delivered four years ago by myself and Open University colleagues, in collaboration with a department of adult social services and an NHS trust in the north west of England. The theme of the workshops was the culture change needed for personalisation to work, and they had been instigated by a very insightful training officer in the social services team. Over a number of workshops, we worked with the participants to explore what personalised care really looked like, and what would get in the way of success. Social workers, service users, occupational therapists, carers, community nurses and others worked together to unpack and explore the issues. It was exciting and inspiring, but it was too much for the community nurses, who felt that their perspective was too different for them to be comfortable, and who concluded that this approach just wouldn’t work for them.

This was genuine discomfort, and it is entirely likely that the same kind of discomfort would be felt in situations where social care staff are in a minority, and the context is more clinical, and it highlights an issue that has to be addressed if integrated care is to work on the ground. And it has to work on the ground if it is to produce the efficiencies in care that are needed, let alone improve the experience of those who use services.

One obvious place to start is in the training and education of future practitioners, and the continuing development of those currently practising. I was pleased, recently, to attend a workshop organised by Health Education England and the Centre for the Advancement of Inter-professional Education (CAIPE) to explore opportunities for future healthcare professionals to learn together, but my enthusiasm was dented somewhat when I realised that much of the inter-professional learning that is currently going on remains firmly in the clinical sphere. So nurses, occupational therapists, pharmacists and physiotherapists are learning together sometimes; but where are the future social workers, administrators and care managers?

The King’s Fund held an event earlier this year prior to the deadline for initial submissions to the Better Care Fund, and reported a relative absence of representatives from acute trusts. Acute trusts, it seems, view the Better Care Fund as a problem, whereas directors of social services see it as an opportunity – just as in our workshops where social care providers saw personalisation as an opportunity but healthcare staff saw only obstacles. These conflicting approaches will continue if we don’t create effective opportunities for staff from across the sectors to learn together in order to work together, and grapple with the culture change that will either make or break integrated care.

References

1. Humphries, R. The Better Care Fund: what’s love got to do with it? King’s Fund (2014).
2. Department of Health. Integrated Care: Our Shared Commitment. (2013).
3. Bennett, Laura; Humphries, R. Making best use of the Better Care Fund. (2014).
4. Department of Health. Enabling Excellence: Autonomy and Accountability for Healthcare Workers, Social Workers and Social Care Workers. (2011).

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