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

University of Bristol

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)

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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)

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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 views46 papers were included, reporting 30 separate studies

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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.

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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.

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Evidence of cost effectivenessCosts 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.

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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.

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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).

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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.

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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.

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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.

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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.

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SCIE Research briefing 41: Factors that promote and hinder joint and integrated working between health and social care serviceshttp://www.scie.org.uk/publications/briefings/files/briefing41.pdf

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