There are few topics in the health field today that generate more interest than that of integrating services. At a time when demographic and epidemiological trends are leading to increasing costs of care, efforts to reduce the rate of spending growth without eliminating services are at a premium.
Human Services Integration is a collection of articles examining how the expectations for integration differ among the various protagonists in human service systems.
The basic questions are: why is it so difficult to integrate services to achieve efficiencies and improved outcome, and why is it that so many attempts at integration never work or become part of the mainstream?
The examples used in the collection come from evaluations of various social services programmes in the US, and as such may be of only limited direct use to a UK audience.
However, while the programmes that are being discussed may be different, the attempts to create efficiency and smooth operation are universal. So, too, are the reasons why the programmes fail, and it is this that is the chief value of the book.
Battles over turf and territory, political squabbles, accountability issues, budgetary needs, personnel shortfalls and many other problems plague all social services workers, not to mention health workers and those in the corporate sector.
The book cites numerous academic studies and evaluations which have tried to assess the reasons why integrative ventures fail and find out how to make them work more successfully. Yet one does not get the sense that the authors have any confidence that merely elaborating the problems that confront successful integration will lead to more successful outcomes.
A good illustration of this comes from the chapter by Catherine Minicucci which describes a neighbourhood based attempt to reorganise the county social services agency into family-centered holistic human service programmes in Del Paso Heights, Sacramento, California. The community was of mixed ethnicity, and it was hoped the programme could be applied to the entire county.
The stated purposes of the project included: enabling people to have the highest quality of life; preserving and strengthening families; making access to needed social services easier; providing multidisciplinary approaches to multiproblem families; assisting families to achieve economic self-sufficiency;
eliminating artificial problem categorisation and adopting a holistic approach;
emphasising personal responsibility;
emphasising proactivity rather than reaction; and being able to evaluate the programme.
In retrospect this seems a pretty substantial agenda for a small county programme, and perhaps a smaller effort would have been more successful.
What was learned after two years of the programme? The following points are discussed:
there were powerful institutional and professional barriers to overcome in getting the programme off the ground and in getting all parties to accept the programme;
more planning, funding, and staff work was needed before the start of the project to work out issues and to get the programme off to a successful start;
the skills needed to market and outreach services are beyond the skills of most governmental agencies and could benefit from professional help;
information needs are critical for both project planning and evaluation, and they must be taken into account early so that measurements can be made;
these projects need a substantial amount of time, patience, and leadership if there is to be a chance to build the support necessary to work effectively;
a great deal of work must be done with the target group to get them to buy into the new project and help to make it successful.
These seem to be rather generic lessons, and they are applicable to many of the examples provided in the book.
There is never enough pre-planning and there is never enough time, and there are always barriers from people afraid that their way of life will be disrupted or their jobs will be changed or eliminated with the new programme.
This does not mean that change can never happen, only that it is difficult to plan for change and that early assumptions about programme form and outcome may differ over time.
This book provides a good review of the (US) literature on the subject of human services integration that may be of value to those planning for new integrative projects. But reading about change and how to make it is very different from actually doing it.