Integrated care requires skills and expertise that already exist but are unequally distributed among the workforce, writes Helen Gilburt
The workforce represents the largest and most important resource in delivering integrated care.
With this in mind, our report commissioned by NHS Employers and the Local Government Association, Supporting integration with new roles and working across boundaries examines the evidence for creating new roles as part of an integrated workforce.
In our research we found a range of new roles which fell into three main areas:
- care coordinators and case managers who liaise between different services to ensure the care of an individual is actively managed across multiple boundaries
- roles that emerge out of existing ones by extending, delegating and substituting skills in order that staff are able to provide more holistic care
- innovative roles such as care navigators and community facilitators who reduce fragmentation and optimise use of health, social care and the community services, while empowering individuals in the process.
Although the majority of the new roles were within the health system, the aim of bridging health and social care is evident in the development of enhanced support and care worker roles to provide not only support, but health and personal care.
Do these roles work?
Many of the organisations which have developed these roles report they create a more flexible and multi-skilled workforce with an ability to improve access.
However, with evaluation focused on the wider processes of integration, there has been limited assessment of individual roles and whether they deliver improved outcomes for patients.
Evidence to support the cost-effectiveness of these roles is also limited. Roles which strengthen integration by reducing the number of staff engaging with a patient, often achieve this by employing more qualified staff, reversing the trend for using the lowest grade staff.
These roles are only cost-saving if they are able to substitute other services, and if these savings are greater than the cost of the role itself. In practice this has proven difficult to achieve, particularly given the often substantial investment required in developing and supporting these roles.
Wider support for new roles
Perhaps the biggest barrier to new roles is how they fit within the wider context and culture of health and social care organisations. The influence of professional identity and organisational identity is one of the most prominent and well documented.
A key mismatch in integration is in how staff define and view each other’s role. At best this can create tension in working collaboratively and at worst has led to denigration of the individual capabilities of staff from different professions and organisations.
Although integrating care may feel like a recent priority, it is certainly not a new endeavour
It is therefore unsurprising that the development of roles which aim to bridge both sectors have proven problematic.
There are also questions around the capacity of individual roles explicitly developed to support integration which can result in individual’s managing high caseloads of people with complex needs, or staff engaging in extended practice on top of the day job with little support.
The potential for upskilling support workers to provide health and social care interventions has received much attention, but a lack of standardised training and differential access brings considerable challenges to development of this workforce.
Developing a ‘boundary-spanning’ workforce
The evidence suggests that organisations should not get distracted by new roles unless they have addressed the fundamentals of integration. Workforce integration and the ability to integrate care is only effective when a number of factors are in place.
These include the extent to which there is wider organisational support and buy-in, resourcing of posts, appropriate management and accountability for staff working across boundaries of care, and the ability to sustain both the activities of integration and the relationships on which many of these new ways of working are reliant.
At the same time, engaging the workforce right from the outset in the aims of integration, not only builds support for new ways of working, but can result in staff identifying and implementing solutions themselves.
Furthermore, (and contrary to the narrative of ‘challenging professional protectionism’) the evidence suggests that actively acknowledging professional boundaries can serve to build trust and respect which in turn enables greater role flexibility.
Community mental health services have a long history of multidisciplinary working, and person-centred approaches increasingly frame the skills of different professions and organisations around the individual needs of service users
Much of the evidence suggests that the skills required for integrated care already exist with the workforce but are insufficiently available or inefficiently distributed.
Recognising the acquisition of knowledge and skills to support integration, and developing ways in which they can be shared, such as through cross-professional and cross-organisational training can greatly support this process.
Although integrating care may feel like a recent priority, it is certainly not a new endeavour.
Community mental health services have a long history of multidisciplinary working, and person-centred approaches increasingly frame the skills of different professions and organisations around the individual needs of service users; both demonstrating that there are established ways of supporting integrated working without the need for new roles.
So while the Vanguard programme and local efforts to integrate care plough forward, the value of building on the lessons to date should not be underestimated.
Helen Gilburt is a fellow in health policy at The King’s Fund