As we move into the new government’s time in office, it is to be hoped that the momentum that has been generated regarding more integrated care is maintained and developed. During the last five years, we have seen a raft of initiatives which seek to address the current fragmentation and the resultant reductions in quality, experience and efficiency. Such integrated initiatives include a common strategic vision signed up to by all parties (the national collaborative), formal partnership arrangements within each local area (health and wellbeing boards), sharing of budgets across health and social care (the Better Care Fund and personal health and social care budgets), national support for innovative practice (integrated care pioneers), care co-ordination for those with most complex needs (named accountable GP for people over 75) and the potential for new organisational forms (multi-specialty community providers).
Most of these initiatives are worthwhile in principle, and if implemented successfully should address some of the barriers that currently prevent successful joint working and so people receiving the integrated care that they deserve and require. However, anyone who is reasonably long in the tooth will know that many similar initiatives have been attempted in the past. To give but a few examples: common vision - national service frameworks; partnership arrangements – learning disability partnership boards; sharing of budgets – pooled budgets in mental health; national pilot programme – partnerships for older people programme; care co-ordination – single assessment process; new organisations – care trusts; and so on. These previous initiatives were also initially surrounded with considerable hope and ambition, only to be subsequently abandoned, sidelined or replaced when new or conflicting initiatives have emerged. In many ways, our problem is not thinking up new and plausible solutions to address fragmentation, but rather giving the ones we have the time and space to achieve their potential. Indeed, it is likely that no model can ensure integrated care all of the time for all of the people, and instead we need to be open to gradual improvement and evolution rather than looking for a big ‘fix’.
The continual internal organisational restructurings and whole system reorganisations, of which we appear to be so fond, add to these difficulties. Somewhat bleakly, the thing that we can say with any degree of certainty is that most of the structures, systems and incentives that are currently in place will be altered or replaced within another five years. Rather than bemoan this reality (although it would be great if a degree of stability did prevail), perhaps the answer then is to identify what is likely to remain and build on this, rather than introducing more eye-catching initiatives with shorter shelf-lives. Two components that have survived the test of time are the centrality of general practice and adult social care teams as the gatekeepers of the two public systems. It would arguably been more sensible to have invested our energy and indeed resources in ensuring that these two services (and the professions that are based within them) are able to act as strong advocates and enablers of integrated care.
Despite the centrality of these two frontline services, the evidence about what enables them to collaborate effectively is surprisingly underdeveloped. The evidence that is available is largely from the late 1990s, which again highlights the long term nature of the relationship. This historical picture is often one of professional tensions, practical misunderstandings and communication difficulties. It does though seem have been possible to improve collaboration with a holistic approach that considered people and culture, as well as systems and process (even if these were often then lost when the inevitable restructurings took place). Moving to the current day, despite the recent interest and partnership initiatives in the 2000s, it appears that the often difficult nature of this core relationship has not moved on significantly. Indeed, the distance between the two services has if anything grown, as social work teams in many authorities have become less patch-based, new, more personalised and bespoke models of care have emerged, and general practices have become larger.
Over the past 12 months the Health Services Management Centre has been supported by the WMAHSN to create development resources that could support better interprofessional working between these two services. Initially, we thought the tricky bit would be to develop stimulating and challenging activities that would be of interest and relevance to all the professions concerned. In fact, the greatest challenge has been the somewhat dull but vital step of recruiting general practices and adult social work teams to participate. This is despite the project requiring relatively low commitment with great potential to improve care for vulnerable people, and also make everyone’s working day a little easier through improving communication and understanding.
We have though now been able to recruit all of the planned participants (to whom great thanks is due) and the experience to date is that even with four hours, the professions concerned can make important learning about their differences and (as importantly) their similarities. Despite the divide that is often suggested between health and social care models of care, participants are finding shared values regarding the independence and autonomy of patients/service users and a shared commitment to using resources efficiently and effectively. There is commonality and empathy regarding the pressures that both services work under, and frustration if the ‘system’ appears to be imposing more distance rather than bringing them together. On this basis, there appears to be some room for optimism regarding the future of integrated care, and it is hoped that at the end of the this parliament we will talking about a quiet revolution in general practice and adult social care relationships, rather than mourning another list of great ideas that have come and gone.
Robin Miller is Senior Fellow and Director of Consultancy at the Health Services Management Centre at the University of Birmingham.