The publication of the latest report on the state of collaboration, partnership and integration across health and social care by the Audit Commission tells a familiar and depressing story (Joining Up Health and Social Care, improving value for money across the interface; Audit Commission, Dec 2011). The report describes the possible financial benefits of better integration across the health and social care interface with a potential saving to PCTs of £132m annually if all adopted the practice of the national average on a limited number of adult care measures such terms of emergency admissions and so on. It describes progress towards effective integration as “patchy” despite many years of policy importance being given to this area. This is yet another salutary reminder of how far we have yet to go to develop smooth and efficient operational practice in the caring services.
Yet for me discussion about integration and partnership seem to always start in the wrong place – driven by considerations of policy and operational neatness, cost savings or pre-emptive organisational take-overs. Despite the rhetoric of patient and user driven integration there are proportionally very few examples in practice – a finding endorsed by the Audit Commission. As someone who has worked at the interface between health and social care for the past thirty years and like many others can see the benefits from better integration around the patient experience or pathway I find this is a considerable frustration – not to say source of anger.
However, to be cool and analytical about the context for integration it is easy to see why so much hot air and buster about joined up services has produced so little tangible evidence of progress. There seem to me to be five factors that need alignment before integration can make headway:
1. Partnership and integration takes leadership, effort, goodwill, capacity and capability – all inputs that are likely to be in very short supply in the current environment of service cuts and retrenchment
2. Integration needs to be focussed, practical and achievable – vague aspirations for partnership are good contextual starting points but they will not deliver the hard outcomes that patients and users need
3. Integration and partnership are often focussed on commissioning and policy staff rather than practitioners – who in turn experience integration initiatives as another top down imperative to which they feel no ownership or obligation particularly if it seen to be another route to cutting services or disempowering practitioners. Without practitioner and clinical leadership integration is likely to fail
4. There is often good and bad reasons for clinicians and practitioners to resist integration and failing to distinguish the patient and centred concerns of staff who have to deal with real people from the natural anxiety and pessimism about change is a recipe for managerial and policy failure. Often staff are passionately against integration proposals not because they are being obstinate or failing to “get on board” the corporate band-wagon but because they know from experience that the proposals are dangerous and wrong
5. We to recognise that sometimes integration can make things worse; not all patient or client pathways benefit from integration and sometimes separate specialisms can lead to safer and more effective intervention.
So what does this add up to? Simply that service integration has a hugely valuable contribution to make to the future of care services but we need a more enlightened much more critical and expert engagement to make if effective. I refer back to the WHO report 2008 found that whilst the evidence base about integration is limited, a systematic review pointed to important lessons:
- Supporting integrated services does not mean that everything has to be integrated into one package. In reality, there are many possible permutations
- Integration isn’t a cure for inadequate resources
- There are more examples of policies in favour of integrated services than examples of actual implementation. Managing change may require action at several levels and requires engagement of health workers and managers, plus a sustained commitment from senior management and policy-makers.
We might also insist on the involvement of users, pateints and citizens in this important dialogue.
In short, whilst cost saving may have a salience and drive at the moment they are unlikely on their own to be the most effective driver for delivering the integrated services users, patients and families demand.
Brian Cox 