Introduction Integration of health and social services has increasingly beena focus of much research and debate in response to the changing demographic of anolder population. Throughout the globe, people are generally living later intoold age. In England, the number of people aged over 65 years rose by 21%compared with 8% for all age groups between 2005 and 2015 (ONS, 2015). This isprojected to increase by a further 21% between 2015 and 2025. Demographicchanges, increasing demand for care and funding constraints have increasedpressures on the health and social care systems (Donovan & Warriner, 2017).
Key measures of the performance of the health and social care sectors areworsening (ONS, 2017). The need to improve the effectiveness and efficiency of treatmentand management of long-term conditions is seen as one of the most significantchallenges to the NHS (Coulter et al, 2013). Joint working between the NHS andlocal government to manage demand and support out-of-hospital care for those withmultiple comorbidity through integration could be vital to the long-term financialsustainability of both the NHS and local government. (NAO, 2017). In the UK, themovement towards integration began in the early 20th century as ameans to generate efficiencies, improve patient satisfaction and clinicaloutcomes, such as a reduction in hospital admissions (Davies,1995) Much of the government legislation related tohealth care over the past 10 years have an increasingly greater focus on integration due to the stark reality of population demographics.
The NHS Five yeawr forward view (2014) aimed to reduce health inequalities andtransfer 20% more care from hospital into the community by 2020. In response,multiple initiatives aimed at reorganising health and care, such as the BetterCare Fund vanguard sights and Transformational Pioneer sites have been rolledout in increasing numbers. Despite this, health and social care systems in the UKremain separate organisations. Defining the problemTraditionally, the medical model of health care provision onwhich the NHS was built, focused on diagnosing and treating disease, often withcare delivered in hospitals and clinics by professionals operating in clearlydefined specialisms.
The success of this approach has in part led to thechanging demographic and the pressing need for a more holistic approach tosupport the longer-term wellbeing of an aging population living with multiplehealth and social needs. In their study of documented models of health andsocial care integration in Sweden over the preceding 10 years, Berglund etal(2015) suggested that older people with multiple co-morbidities need acomplex mix of strategies at different organisational levels in order tooptimise outcomes, including national agreements and local level co-ordinationand co-operation. The increasingly pressing challenge for organisations is toreform the way health and social care is delivered to people with multimorbidity,in order to increase quality in terms of effectiveness and efficiency and also sustainabilityin terms of cost and the workforce. Integration is widely seen as the means toachieve this aim.In consideration of how integration can be delivered, threemain themes emerge from a synthesis of the literature ( see appendix ). These are integration at an organisationallevel, at workforce level and at the interface of care delivery (Petch, 2012, Beechet al, 2013); Berglund et al, 2015 ).
Much of the political legislation and guidancearound integration over the past 40 years advocates for aligning heath at anorganisational level, including the Health and Social Care Act (2014) and NHSFive Year Forward View (2014). Thehealth and social care act (2014) introduced a new legal duty requiring healthand social care bodies to share information to facilitate personalised careplanning. An early pioneer of organisational integration which has beenevaluated and cited in many studies is the Torbay and South Devon TransformingCommunity Services Agends (Thistlethwaite, 2011). In this pilot study, leaderswith social care backgrounds were recruited into strategic senior roles. Theresult was to overcome resistance to integration that stemmed from feelingsthat social services were being taken over by the NHS. The support of seniorleadership is seen as crutial for establishing a framework for integrationwhich supports the development of collaborative processes (Gilburt, 2016).
Separate funding arrangement is also widely cited in the literatureas a barrier to effective integration ( Bardsley et al, 2013; Buse, 2010). Followingthe government report, Living Longer Living Better which describned how careshould be organised for people with long term conditions, NHS England attemptedto inject momentum into the integration agenda by setting up a Sustainabilityand Transformation fund to pay for local projects including work to integrateservices by 2020. However, financial pressures have resulted in funds being divertedto shore up Trust deficits (NA0, 2017). Funding arrangement for new care modelsalso took the form of the Btter Care Fund. To receive this funding, Trusts wererequired to apply to be Vanguard sights via a process that linked monies toperformance trajectories. A review of Vanguard sights by the National AuditOffice concliuded that, while there are some positive examples of integrationat the local level, evaluations of initiatives to date have found no evidenceof systematic, sustainable reductions in the cost of care arising fromintegration. More locally, Manchester has become the first UK city to In response to legislation, NHS England produced guidance onhow to implement integration (Coalition for Collaborative Care, 2015) which advisedthat attempts should be made to integrate the care planning process to supportthe individual and avoid duplicating monitoring regimes.
The true meaning of health and social care integration is aquestion debated in a high amount of academic literature, prompting Leathard(2003) to describe the vast array of approaches as a “terminological quagmire”.Some of the discourse stems from the fact that complex systems are beingconsidered. The organisation and delivery of health and social care are complex,and the focus of service provision is often around people with the greatest complexityof need (Leutz, 1999).
The overarching meaning behind the drive forco-ordination is to align health and care services, making sure that they aredesigned around the needs of individual service users, and delivered in thecommunities where people are living (Donovan & Warriner, 2017). If we areto move towards designing services around the individual, it is important toconsider service users’ expectations of integration. To this end, a coalitionof health and social care charities came together to from the charitableorganisation, National Voices, with the aim to develop a common understandingof what service users wanted from an integrated system of care and support(National Voices, 2013). In their report ‘A narrative for person-centredcoordinated care’, the coalition set out a number of “I statements” whichdefined the terms of integrated services. This demonstrated the pivotal role ofeffective, personalised care and support planning as a means to achieve theaims of integration. The following ‘I statement’ illustrates this aim:”If I have complex health and care needs, the NHS and socialcare work together to assess my care needs and agree a single plan to cover allaspects of my care.”