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Document Information

Title

The Determinants of Effective Integration of Health and Social Care

Date

February 2013

Purpose

This document is one of the first products issued by the Integrated Care Workstream of the Health and Wellbeing Best Practice and Innovation Board. It has been commissioned by the Welsh Government to support integrated health and social care policy development, and provides all interested parties with a summary, based on a review of the available evidence, of the determinants of effective health and social care integration.

Sponsor

Paul Matthews Chief Executive Monmouthshire County Council (In his capacity as Integrated Care Workstream Lead Health and Wellbeing Best Practice and Innovation Board)

Target Audience

Welsh Government, NHS Wales; local government; third sector; independent sector; academia, all other interested parties.

Timing

This document has been issued in February 2013 to support the development of the Welsh Government Framework for Integration.

Contact details

Sheena Jones Board Administrator, Programme Management Unit 4th Floor Churchill House Churchill Way Cardiff CF10 2HH

02920 503479 Sheena.Jones@wales.nhs.uk

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The Determinants of Effective Integration of Health and Social Care

Purpose

The Health and Wellbeing Best Practice and Innovation Board (‘the Board’) has been established by the Welsh Government Minister for Health and Social Services to accelerate the adoption of innovation and the dissemination of best practice relevant to health and social care in Wales. In taking the work forward, the Board has used the learning from work undertaken in other parts of the UK1 to inform its initial work programme.

As one of its initial actions, the Integrated Care Workstream of the Board has been asked to provide advice to Welsh Government on the determinants to drive health and social care integration. This advice will be used to support national policy development, including the development of, and implementation of, a Framework for Integration. The Board will then act as a reference group in support of implementation.

This paper provides Welsh Government with the required advice, and, in addition to reflecting contemporary evidence on the determinants of effective health and social care integration, it includes the input and expertise of Board members and references a growing evidence base, much of which is contemporary.

Definitions – what do we mean by Integrated Care?

There are many definitions of integrated care, reflecting the degree of integration and the maturity of the collaboration and partnership relationships in place2. The English Integrated Care Network defines Integrated Care as ‘a single system of needs assessment, service commissioning and/or service provision’3, whilst the World Health Organisation recognises the different models that exist and describes a range of vertical and/or horizontal integration happening across organisational boundaries4.

Whatever definition is adopted, those organisational and cross sectoral service models in place include a number of key principles, whether explicit within definitions, or implicit. These have been summarised by a report in 20105 as:

The need to target integration where it is most needed – it is not a solution for all groups;

The need to recognise and develop strategies to manage fundamental differences across sectors, such as the management and accountability mechanisms related to resources;

The recognition that integration is not a ‘quick win’; it requires investment – both in time and resources - to establish and progress what can be complex cultural and systems change;

It should be designed in partnership with service users, and have citizen centred services at its core;

It requires local ‘buy in’ – policy statements alone will not result in an effective and sustained model of integrated services.

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Reflecting policy requirements6, the Welsh Government ‘Case for Change’ – the reasons why we need to move towards integrated health and social care services for appropriate groups – is based on:

recognition that person centred services delivered as a single model of service delivery provide better quality care and result in improved outcomes;

demographic projections of an increasingly older population, both in numbers and as a proportion of the general population, with a significant increase in the very elderly – those aged 85years and over7;

the increased incidence of chronic conditions based upon an increasingly older population and poor lifestyle choices;

the increased incidence of dementia that longevity brings – a 30% increase is projected in Wales in the coming decade alone. In some rural areas the numbers are projected to increase by 44%8;

the need to provide co-ordinated, single service responses to promote and protect what can be fragile independent living.

Annex 1 provides a schematic representation of the Case for Change.

Creating the Environment: the conditions for successful integration

of health and social care

Effective partnership working is essential if collaborative models are to be developed and sustained across health and local government partners. Reports commissioned by NLIAH9 suggest a wide range of factors and influences shape partnership working. The Figure 1 below10 illustrates these factors.

Figure 1: Factors Influencing Collaborative Working

From a structural perspective, the evidence base for integrated services reflects the differing national policy contexts across the UK countries. In England much of the

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published research on integration refers to primary and secondary healthcare integration, rather than fully integrated health and social care services for appropriate client groups. Comparisons between UK countries based upon headline “integrated services” models need therefore to be treated with some caution.

All UK countries are highlighting the anticipated value of integration, and promoting integrated services as an appropriate service model to deliver shared care to those client groups likely to be high users of health and social care services - older people, adults with a learning disability, and children with long term complex needs. Demographic projections of an increasingly ageing population with a range of chronic diseases, linked with the challenging resource position experienced by public sector services across the UK, make efficient shared service models that ensure the best use of public resources a priority. There are academic and policy studies that focus on England11, Scotland12 and Northern Ireland13. UK wide and country specific policy analysis has also been undertaken by national organisations including the King’s Fund14, the Nuffield Institute15, the School of Public Policy16, and national social care organisations17.

On an international basis, other research studies have looked at Finland, Denmark, New Zealand, Norway and Sweden. One key source for international information was a literature review carried out for the RCN in Scotland18.

In Wales, there is increasing recognition within Government policy19 of the potential value of integrated service models in providing a more proactive approach to older people’s services, seeking to protect what can be fragile independent living via community based models of care that are person centred and delivered within the person’s usual place of residence.

The integrated health board model in Wales provides a structural health model to address primary/community and secondary healthcare interfaces, delivering healthcare across all locations to the population of Wales. The geographical footprint of the health boards, and the synergy with local government boundaries, also seeks to encourage and support partnership working.

The Key Determinants of Effective Integration of Health and Social Care The evidence indicates that there are a number of determinants that influence the shape of effective integration of health and social care:

Clarity of strength of purpose - having a shared vision, culture and values that deliver person centred services based on shared outcome frameworks;

Collaborative leadership at all levels, with expert change management skills and the ability to drive cross sectoral working20

A culture of learning and knowledge management, that seeks to support the sharing of best practice, improvement and service development across organisational and sectoral boundaries;

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A supportive legislative/policy environment that seeks to create the environment within which integrated services can develop;

Integrated management structures, incorporating the use of joint appointments, with unified leadership and joint governance arrangements and accountability21;

Trust based interpersonal and interprofessional multidisciplinary relationships across sectors, building on the strengths and unique contribution of each partner22;

Appropriate resource environments and financial models seeking to ensure collaborative financial models, including the need for pooled budgets23;

Comparable IT and information sharing systems that facilitate ease of communication;

Unified performance management systems and common assessment frameworks;

Collaborative capabilities and capacities, with all practitioners being skilled in integrated working and management.

These key determinants and the evidence base attributed to them are set out in the table below.

Determinant

Evidence / Literature

Clarity of strength

and purpose, with

shared vision,

culture and values

A shared vision and common goals are crucial to the success of

integrated care, whatever the model. The Care Programme

Approach to mental illness in England was undermined by the

lack of a shared vision. (Simpson, Miller and Bowers, 2003)24.

In Northern Ireland health and social care trusts have

established professional forums to deal with problems arising

from cultural differences. Forums focus on issues of

professional development, training and governance. They also

provide peer support and information on good practice and

research. (Heenan and Birrell, 2006)25.

The importance of clear, realistic and achievable aims and

objectives, understood and accepted by all partners.

Differences in organisational processes, priorities or planning

cycles can create a climate for conflict rather than co-operation

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(Cameron and Lart ,2003)26.

Steve Woolgars27 defines innovation as “the art of interesting

an increasing number of allies who will make you stronger and

stronger”.

Story-telling and narrative databases are more powerful in

moving knowledge around organisations and communities than

guidance notes, instructions and codes of practice28.

Collaborative

capabilities and

capacities

Managing and working in integrated settings differs from uni-

organisational settings, and needs different skill sets (Getha-

Taylor, 200829; San Martin Rodriguez et al, 2005)30

Joint training is considered central to building a shared culture.

Cross-agency secondments also helped to prepare people from

different agencies and professional backgrounds for integrated

working and to appreciate other people’s roles and

perspectives. (Stewart, Petch and Curtice, 2003)31.

Collaborative

leadership

There is a key role for leaders at all levels exercising the types

of leadership that work across organisational and sectoral

boundaries to create the environment within which integration

can flourish. The skills and challenges of working across

sectors to deliver a single service model will need to be

identified and supported through a single knowledge

management approach32.

Leaders are also pivotal in ensuring that organisations and

systems learn from others, both within and outside their sector.

In 2013/14, the Board will provide advice on leadership, culture

and climate determinants.

Learning and

knowledge

management

The integration of health and social care is an exercise in

learning and knowledge management, because it involves the

‘collision of diverse stakeholders searching for new ways of

working’ (Williams, 2012)33; (Nicolini et al, 2008)34

Integrated

management

structures

There are two parts to this: ‘soft’ issues such as culture, training

and attitudes, and ‘hard’ issues like employment terms and

conditions (Hultberg et al 2005)35.

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In Norrtälje (Sweden) in which a single organisation administers

a combined health and social care budget to purchase services

from a second, integrated provider of health and social care

services leading to a flatter management structure, and greater

integration of primary, secondary and tertiary care with social

care (CEEP, 2007)36.

Focusing on improving patient care in integrated structures

helps to overcome professional boundaries (Heenan and Birrell,

2006).

Resources,

incentives and

pooled budgets

Health and social care sectors are facing resource challenges

that are unprecedented, and the consequences of austerity

upon integration and collaborative working will need to be

considered, reflected and addressed within a national

framework. The opportunities that austerity brings to innovate

and develop truly groundbreaking models of cross sectoral

working should be exploited37.

Incentives have a strong part to play, with financial incentives

having an ability to shape behaviour and influence practice.38

Specific to pooled budgets, experience from Northern Ireland

suggests a single source of funding, used to deliver integrated

care is a significant success factor. In separate organisations,

funding earmarked for either health or social care cannot easily

be redirected from one service to the other as managers cannot

commit resources from budgets they do not control (Heenan

and Birrell, 2006)2

Where a single budget exists, the medical profession and a

medical model of care can lead to funds being diverted from

community-based services to support hospital services as acute

care takes priority. This has been observed in Northern Ireland

(Heenan and Birrell 2006) and New Zealand (Ham et al,

2008)39.

Integrated structures and are not enough in themselves to

secure integrated service delivery. Budgets need to be

integrated too. (Reilly et al 2003)40.

Pooled budgets succeeded in improving interdisciplinary

working in Sweden although negative attitudes towards other

professions took some time to decrease (Hultberg et al,

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2005)41.

Trust based

interpersonal and

interprofessional

relationships

Good inter-professional collaboration is associated with

success measured by lower hospital admission rates, fewer GP

visits and improved patient function in studies of people with

long-term conditions (Reed et al, 2005)42.

Sharing office space and client groups makes integrated

working easier. (Wistow and Hardy 1991)43.

Outcomes from a care programme approach were better when

clinical staff worked in multi-disciplinary teams with social care

staff (Hofmarcher, Oxley and Rusticelli, 2007)

The perceived lower status of social care staff compared to

healthcare staff created significant difficulties in developing

integrated systems (Coxon, 2005).

A number of studies have concluded difficulties in securing GP

involvement. (Cameron and Lart’s literature review 2003)44.

A supportive

legislative and

policy context

Much of the commentary on integrated care highlights the

importance of a legislative and policy framework that

consistently supports and encourages integration. Danish

authorities took care to avoid perverse financial incentives that

would otherwise promote institutional care and these acted as a

further incentive to develop community-based care services

(Stuart and Weinrich, 2010)45.

The need to align policy, evidence and practice is also

highlighted in an analysis of the policy position in England and

Scotland (Petch, 2012)46

Compatible IT and

information

sharing systems

Good communication improves the ability of teams to work

together successfully (Howarth, Holland and Grant, 2006)47.

Clear communication structures are needed to keep all staff

aware of, and involved in, the processes surrounding integrated

care, design and implementation.48

Complex documentation, poor record keeping, incompatible IT

systems and differences in referral arrangements cause

problems (Cameron and Lart, 2003).

Robust information systems for rapid communication between

sectors/organisations and within teams including using a single

record gathered from shared assessments (Reed et al, 2005)

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Unified

performance

management

systems and

common

assessment

framework

The need for unified performance systems, and a single

approach to assessment has been identified as essential for

over a decade49 50 51.

In Wales, the need for a unified outcomes based approach to

measuring success, along with a common assessment process

and the introduction of national eligibility criteria are reflected

within developing legislature52

.

Conclusion

This paper has set out the determinants for the effective integration of health and social care services. It is being submitted to the Directorate of Strategy and Policy, Department for Health, Social Services and Children, Welsh Government in February 2013 in support of the development of the national Framework for Integration. In addition to the determinants set out above, there is, as yet, no Integrated Care Network specific to Wales that could act to support and guide change. The development of a cross cutting and interactive learning and knowledge management network across health and social care could promote engagement from those involved in service delivery, seeking to develop a robust learning and development environment to drive sustainable change. Such a network could also serve to signpost emerging models and innovative approaches being progressed from national organisations such as the Kings Fund, the Nuffield Institute, and the Public Services Academy, University of Birmingham. The Board recommends the development of such a network in Wales.

Next Steps for the Best Practice and Innovation Board

Having delivered the initial advice on the key determinants, 2013/14 will see the Board focus on:

The leadership, culture and climate needed to promote integration;

Effective employee engagement in this agenda;

Providing more evidence based case study material on the effective integration of health and social care in Wales.

The Board will also act as a Reference Group for the roll out of the Framework for Integration.

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Demographic projections

of an increasingly ageing

population as a

proportion of the

general population

* Adapted from Transforming your Care: A Review of Health and Social Care in Northern Ireland (2011)

Unstable health and social care

systems – limited capacity in

the face of increasing demand,

reduced workforce, reduced

funding

Poor lifestyle choices leading

to poor health and an

increase in the numbers

with chronic conditions

The Consequences:

Inability to deliver person centred services.

Increasing gap between demand and capacity to meet need.

Limited ability to focus on preventative models of care that support independent living.

Increasingly reactive model of health and social care delivery, with an inability to plan for and meet growing need.

Poor outcomes, increasing reliance on high levels of care and support and constantly reacting to increasing need.

Disjointed care delivered in a poorly co-ordinated way.

A workforce that is unable to operate across sectoral boundaries.

Integrated Health and Social Care: The Case for Change*

Increasing pressures upon health and social care services

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‘Innovation, Health and Wealth: Creating Change One Year On’ (2012) Department of Health 2, ‘From the Ground Up: A report onreport on integrated care design and delivery’ (2010), Department of

Health in partnership with the Institute of Public Care, community Health Partnerships, and the Integrated Care Network. 3 Thistlethwaite, P. (2008), A Practical guide to integrated working. Integrated Care Network.

4 Lloyd, J. And Wait, S. (2006), Integrated Care: A Guide for policymakers.

5, ‘From the Ground Up: A report onreport on integrated care design and delivery’ (2010), Department of

Health in partnership with the Institute of Public Care, community Health Partnerships, and the Integrated Care Network. 6 Setting the Direction (2009) Welsh Government

Sustainable Social Services (2011) Welsh Government Together for Health (2012) Welsh Government 7 Daffodil Care Needs Projection System, Welsh Government

8 Ibid

9 Working in Collaboration: Learning from Theory and Practice, Cardiff. NLIAH (2007)

Learning to Collaborate: Lessons for Effective Partnership Working in Health and Social Care, Cardiff. NLIAH (2007) 10

Ibid 11

Ham, C. And Oldham, J. (2009) “Integrating Health and Social Care in England: Lessons from Early Adopters and Implications for Policy”, Journal of Integrated Care, 17 (6) 3-9 Tucker, H (2010) “Integrating Care in Norfolk – Progress of a National Pilot” Journal of Integrated Care, 18 (1) 31-37 12

Petch, A. (2012) “Tectonic plates: aligning evidence, policy and practice in health and social care integration”, Journal of Integrated Care, 20 (2) 77-88 13

“Transforming Your Care: A Review of Health and Social Care in Northern Ireland (2011) Northern Ireland Executive 14

Goodwin, N., Perry, C et al (2012) “Integrated care for patients and populations: improving outcomes by working together. Kings Fund and Nuffield Trust Naylor, C. ,., Appleby, J. (2012) “Sustainable health and social care”. Kings Fund. Humphries, R (2011) “The Unifying Principle of Integration” Kings Fund Humphries, R., Curry, N (2011) “Integrated Health and Social Care” Kings Fund 15

Ham, C. (2009) “Policy options for Integrating Health and Social Care” Nuffield Trust 16

Ham, C. (2006) “Developing integrated care in the NHS: adapting lessons from Kaiser”. Health Service Management Centre School of Public Policy, University of Birmingham

13

Ham, C. (2010) “Working Together for Health: Achievements and Challenges in the Kaiser NHS Beacon Sites Programme”, Health Service Management Centre, University of Birmingham 17

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http://www.rcn.org.uk/__data/assets/pdf_file/0008/455633/Hilarys_Paper.pdf 19

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Cameron, A. and Lart, R. (2003), “Factors promoting and obstacles hindering joint working: A systematic review of the research evidence”, Journal of Integrated Care, 11 (2), 9-17 27

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San Martin-Rodriguez, L., Beaulieu, M-D., D’Amour, D. And Ferrada-Videla , M. (2005) The determinants of successful collaboration: a review of theoretical and empirical studies. Journal of Interprofessional Care, 19 (Suppl. 1) 132-147. 31

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36

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