Is integration the burning platform for change

1. Is integration the ‘burning
platform’ for change?
Ailsa Cameron & Dr Rachel Lart, School for Policy Studies,
University of Bristol

2. 2
Background
Our previous review of the joint working literature
concluded that ….
‘the vast majority of the studies in the review focused
their attention on the process of joint working and the
perceptions of those involved as to its success. Very few
of the studies looked at either the prior question of why
joint work should be seen as a ‘good thing’ and
therefore why it should be done or at the consequent
question of what difference joint working made’
(Cameron, et al. 2000)

3. 3
Since that time
• Reforms introduced by New Labour have had time to
effect change.
• The pressures driving government interest have
intensified.
• Joint working & integration continue to be important
strategies in the provision of adult health and social
care services in England. However,
• there is continuing concern that the evidence base
remains inadequate(Rummery 2009)

4. 4
SCIE review
Aimed to describe:
• different models of working between health and
social care services at the strategic, commissioning
and operational levels
• evidence of effectiveness and cost-effectiveness
• factors promoting and obstacles hindering the
success of these models
• service user and carer views
46 papers were included, reporting 30 separate studies

5. 5
Models
• Multiagency teams,
• Placements of individual staff across agency
boundaries,
• Single assessment processes (SAP),
• Provision of intermediate care, structurally
integrated services, and
• Use of pooled budgets.

6. 6
Evidence of effectiveness
• Clinical outcomes - improvements in quality of life,
health, well-being and coping with everyday living
were reported but comparative studies suggest only
marginal differences.
• Avoid inappropriate admission to acute / residential
care - Evaluations of intermediate care services found
reduced inappropriate admission to care.
• Remaining at home - the organisation of services
doesn’t improve the likelihood of living at home;
rather need/ access to support are key factors.

7. 7
Evidence of cost effectiveness
Costs and cost effectiveness - assessing costs and cost-
effectiveness was complicated making it difficult to
confirm cost effectiveness. However some evidence
that intermediate care can save costs.
Service organisation, service use and costs - analysis of
costs across districts providing community mental
health services demonstrated the impact of service
need not organisational structure on costs. But some
evidence that integrated services were no more costly
than discrete services.

8. 8
User and carer experiences
• Service user and carer experiences were not
routinely included in evaluations.
• But when they are - users report high levels of
satisfaction with integrated services, valuing timely
assessments, responsiveness, trusting relationships
with key workers, improved communication
between agencies and help navigating complex
systems.
• Users do not comment on how services are
arranged, rather they report on the access &
appropriateness of services.

9. 9
Factors promoting & hindering
Our original categories remained informative:
organisational; cultural & professional and, contextual.
Within these categories a number of themes received
less attention than in our original review (co-location &
coterminosity), while some new themes emerged (role
flexibility).

10. 10
Factors promoting & hindering
cont
Disappointingly, some factors hindering joint working
were stubbornly persistent: difficulties in
communication & information exchange, differences in
professional perspectives, lack of trust.
Consistent message about factors promoting joint
working: stability, continuity in relationships, previous
positive experiences.

11. 11
Factors hindering integration
Studies focused explicitly on service or organisational
integration reported a number of factors that suggest
some ambivalence and even hostility towards
integration. These included:
A lack of understanding of integration;
Divergent and competing organisational aims;
Professional misunderstandings & rivalries;
Concern that the contribution of community health and social care might
be marginalised by acute care.

12. 12
Is integration the burning
platform for change?
The review demonstrates that more emphasis is placed
on outcomes & there is evidence of impact. But the
evidence is less than compelling.
There is a need for:
•Greater clarity about what ‘integration’ is and it’s intended purpose. Are we
talking about organisational integration or integration within health/social
care systems?
•New approaches to tackle some of the more persistent obstacles to joint
working.
•More robust evidence of impact, including services users experiences of
integrated services.

13. 13
A turbulent future?
• Integration remains a key element of policy: Health
and Social Care Act 2012, White Paper 2012. But
different strands of health and social care reform
confound the context known to support successful
joint working.
• Reform of community health service encouraging horizontal/ vertical
integration and increasing the diversity of providers.
• The development of social work practices.
• Providers compete rather than collaborate for contracts.
• Changes to the working conditions of professionals undermine
collaborative relationships.
• Government needs a more persuasive narrative.

14. 14
SCIE Research briefing 41: Factors that promote and
hinder joint and integrated working between health
and social care services
http://www.scie.org.uk/publications/briefings/files/briefing