The importance of integration to health and social care is undoubted, but there is still some confusion over how it will work. It is up to leaders at both a national and local level to develop new approaches that will ensure integrated care is a success, says Dr Rebecca Rosen.
Integration remains a central theme in the Health and Social Care bill, with work in progress around the country to try and make services less fragmented for patients and their carers.
At a recent workshop exploring how integrated care might be developed at pace and scale, which marked the launch of a new Nuffield Trust and King’s Fund project to support the development of a national strategy for the promotion of integrated care, participants agreed that financial pressures have created a ‘burning platform’, and that integration could improve patient experience and deliver the service efficiencies required by the QIPP agenda.
But they also reported a widespread reluctance on the part of local managers and clinicians to use the policy leavers and opportunities that already exist to support integration.
This implies that organisations are waiting for a top-down blue-print on “how to do integration”, along with a set of clear rules on what will and won’t be allowed .
In a speech to The King’s Fund on 20 October, minster for care services Paul Burstow highlighted some of the many ways of thinking about integration. He cautioned against a narrow focus on physical health and long term conditions, emphasising the interplay between psychological and physical health problems and wider social influences, emphasising the need to address all these dimensions in the services we develop.
The speech reminds us that integration is a slippery concept to deal with - hard to define, understood differently by those working to deliver better co-ordinated care, and with few validated measures through which to chart progress.
The Nuffield Trust’s recent report: What is integrated care? helpfully examines the meaning of integration and integrated care but, however it is defined, three themes should remain at the heart of local initiatives to develop more integrated services:
- organising care around the needs of patients;
- co-ordinating the work of the professionals who deliver services; and
- aligning the incentives that shape the behaviour of individuals and organisations.
It is widely recognised that national policy, regulation and payment systems are important in creating a supportive context for integration, but local action on these three fronts is equally relevant.
People who use health and social care services aren’t fussed about whether they are “integrated”, “shared” or “joint”, but they do mind if they waste time and effort having the same test twice or if they are given conflicting advice by different professionals. .
With this point in mind practical solutions for integrated care emerge: a key worker for each patient or client; “single point of access” phone numbers; and shared electronic records.
However, these are only part of the story. Various reports have highlighted the contribution of leadership, organisational culture and context to integrated care (for example, Integration in Action: four international case studies, and Commissioning Integrated Care in a Liberated NHS).
Successful integration requires senior executives committed to changing the way care is provided across teams and organisations, and professional staff who are passionate about individualising care in line with each person’s needs and preferences.
Coordinating the work of professionals should result in more consistent standards of care - wherever and by whom it is delivered.
And what of aligned incentives? Much has been written about the need for financial incentives that drive organisations to collaborate in the delivery of integrated care. New types of tariff and “year of care payments” are being developed for the NHS and may indeed help.
However, opportunities already exist to develop shared budgets across different organisations (for example, pooled health and social care budgets). Targeted financial incentives are in widespread use to influence professional behaviour (for example, through QoF payments to GPs); and new outcomes measures have been proposed that will require collaboration between hospital and community providers (for example, reductions in emergency admission and re-admission rates).
National guidance is under-development and will provide a framework around which to develop integrated services.
But this will not be a step-by-step guide on “how to do it”. Those with an interest in integration need to kick-start the process now by finding local leaders who are passionate about working in new ways to improve clinical outcomes and the day-to-day experience of patients.
There is no time like the present to get going.