The listening exercise is over and the results are in; the NHS Future Forum insists integrated care must underpin how health and social care is delivered – and they are right. But do we really understand what this means, and what it implies?
As our recent event on the role of integrated care highlighted, the true meaning of the term ‘integrated care’ remains elusive. It is the equivalent of the psychologist’s ink-blot test – meaning different things to different people – enthusing some, threatening others, bemusing many.
Most can agree that integrated care is person-centred, bringing together formerly fragmented and sub-optimal services to significantly improve the quality and experience of care to individuals. Research shows that there are many different ways of doing this, and that – where implemented appropriately – patient experiences and care outcomes can improve significantly.
However, history tells us just how difficult it is to turn the concept of integrated care into an operational reality: most of the schemes that promoted integrated care in the past have perished, and only a few very good examples have stood the test of time.
To explain some of the reasons for this is it is worth going back to examine the ‘five laws’ of integrated care developed by Walter Leutz following his observations of the process in the UK and USA. These laws contain enduring truths.
Law 1: You can’t integrate all of the services for all of the people
The fundamental questions here are: who you should target for integrated care?, and what intervention is the most effective to use? Get the answers wrong and the result will often be unnecessary or uneconomic. For example, case management is a labour-intensive approach that is unlikely to be cost effective unless it is targeted accurately. Much of the evidence in the UK shows there remains a steep learning curve to getting this right.
Law 2: Integration costs before it pays
Costs are unavoidable, but savings are not assured. There is an element of risk in integration, and this has never sat well with the risk-averse culture in health and social care (let alone in the current financial environment). As a result, and on the basis that it’s far better to risk someone else’s money rather than your own, many integrated care schemes remain limited to grant-funded and/or small-scale pilots with no real sustainable commitment behind them.
Law 3: Your integration is my fragmentation
Even if a manager implicitly recognises the benefits of integrated care, they may feel it undermines or fragments their role. By its very nature, the process of integrated care requires strong leadership and skillful handling to broker the partnerships required to make it work. This is why so much research in this area focuses on the development of social capital to foster a common vision for change, and why financial inducements or enforced accountabilities alone can often commercialise relationships rather than promote collegiate working.
Law 4: You can’t integrate a square peg into a round hole
All integrated care is local and no one model can be effectively prescribed. Whereas the problem to resolve may look similar, (say, reducing re-admission rates to hospitals because step-down care is inadequate), the approach to solve it must be adapted to meet local circumstances. Hence, integrated care is not a solution that can be implemented wholesale or imposed from on high. It must be built from the bottom up, driven by local ownership, within a system that rewards this.
Law 5: The one who integrates calls the tune
Integrated care has largely been the business of providers and has not necessarily reflected the values of patients and communities. Indeed, in many cases, dominant professional elites can emerge, reflecting their own values and interests above others. Effective integrated care networks need skilled managers to broker a common path between partners that have competing interests. True ‘coalitions of the willing’ are rare.
There is a clear need for a more integrated health and social care system. Yet making integrated care work locally has been variously described as ‘pushing a boulder uphill’ or ‘swimming against the tide’ due to the inherent difficulties in the process.
Much of the success of the government’s integrated care project will therefore rest on consistent system leadership at the top to turn this tide and support local innovation. Revisions to the Health and Social Care Bill mean that integrated care should be explicitly promoted, potentially providing the stimulus towards this enabling environment. A window of opportunity has been created that is too important to miss.