Introduction & Warriner, 2017). Key measures of the performance



Integration of health and social services has increasingly been
a focus of much research and debate in response to the changing demographic of an
older population. Throughout the globe, people are generally living later into
old 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 is
projected to increase by a further 21% between 2015 and 2025. Demographic
changes, increasing demand for care and funding constraints have increased
pressures on the health and social care systems (Donovan & Warriner, 2017).
Key measures of the performance of the health and social care sectors are
worsening (ONS, 2017). The need to improve the effectiveness and efficiency of treatment
and management of long-term conditions is seen as one of the most significant
challenges to the NHS (Coulter et al, 2013). Joint working between the NHS and
local government to manage demand and support out-of-hospital care for those with
multiple comorbidity through integration could be vital to the long-term financial
sustainability of both the NHS and local government. (NAO, 2017). In the UK, the
movement towards integration began in the early 20th century as a
means to generate efficiencies, improve patient satisfaction and clinical
outcomes, such as a reduction in hospital admissions (Davies,1995)  Much of the government legislation related to
health 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 and
transfer 20% more care from hospital into the community by 2020. In response,
multiple initiatives aimed at reorganising health and care, such as the Better
Care Fund vanguard sights and Transformational Pioneer sites have been rolled
out in increasing numbers. Despite this, health and social care systems in the UK
remain separate organisations.

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Defining the problem

Traditionally, the medical model of health care provision on
which the NHS was built, focused on diagnosing and treating disease, often with
care delivered in hospitals and clinics by professionals operating in clearly
defined specialisms. The success of this approach has in part led to the
changing demographic and the pressing need for a more holistic approach to
support the longer-term wellbeing of an aging population living with multiple
health and social needs. In their study of documented models of health and
social care integration in Sweden over the preceding 10 years, Berglund et
al(2015) suggested that older people with multiple co-morbidities need a
complex mix of strategies at different organisational levels in order to
optimise outcomes, including national agreements and local level co-ordination
and co-operation. The increasingly pressing challenge for organisations is to
reform 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 sustainability
in terms of cost and the workforce. Integration is widely seen as the means to
achieve this aim.

In consideration of how integration can be delivered, three
main themes emerge from a synthesis of the literature ( see appendix  ). These are integration at an organisational
level, at workforce level and at the interface of care delivery (Petch, 2012, Beech
et al, 2013); Berglund et al, 2015 ). Much of the political legislation and guidance
around integration over the past 40 years advocates for aligning heath at an
organisational level, including the Health and Social Care Act (2014) and NHS
Five Year Forward View (2014).  The
health and social care act (2014) introduced a new legal duty requiring health
and social care bodies to share information to facilitate personalised care
planning. An early pioneer of organisational integration which has been
evaluated and cited in many studies is the Torbay and South Devon Transforming
Community Services Agends (Thistlethwaite, 2011). In this pilot study, leaders
with social care backgrounds were recruited into strategic senior roles. The
result was to overcome resistance to integration that stemmed from feelings
that social services were being taken over by the NHS. The support of senior
leadership is seen as crutial for establishing a framework for integration
which supports the development of collaborative processes (Gilburt, 2016).

Separate funding arrangement is also widely cited in the literature
as a barrier to effective integration ( Bardsley et al, 2013; Buse, 2010). Following
the government report, Living Longer Living Better which describned how care
should be organised for people with long term conditions, NHS England attempted
to inject momentum into the integration agenda by setting up a Sustainability
and Transformation fund to pay for local projects including work to integrate
services by 2020. However, financial pressures have resulted in funds being diverted
to shore up Trust deficits (NA0, 2017). Funding arrangement for new care models
also took the form of the Btter Care Fund. To receive this funding, Trusts were
required to apply to be Vanguard sights via a process that linked monies to
performance trajectories. A review of Vanguard sights by the National Audit
Office concliuded that, while there are some positive examples of integration
at the local level, evaluations of initiatives to date have found no evidence
of systematic, sustainable reductions in the cost of care arising from


More locally, Manchester has become the first UK city to  

In response to legislation, NHS England produced guidance on
how to implement integration (Coalition for Collaborative Care, 2015) which advised
that attempts should be made to integrate the care planning process to support
the individual and avoid duplicating monitoring regimes.


The true meaning of health and social care integration is a
question 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 being
considered. The organisation and delivery of health and social care are complex,
and the focus of service provision is often around people with the greatest complexity
of need (Leutz, 1999). The overarching meaning behind the drive for
co-ordination is to align health and care services, making sure that they are
designed around the needs of individual service users, and delivered in the
communities where people are living (Donovan & Warriner, 2017). If we are
to move towards designing services around the individual, it is important to
consider service users’ expectations of integration. To this end, a coalition
of health and social care charities came together to from the charitable
organisation, National Voices, with the aim to develop a common understanding
of what service users wanted from an integrated system of care and support
(National Voices, 2013). In their report ‘A narrative for person-centred
coordinated care’, the coalition set out a number of “I statements” which
defined the terms of integrated services. This demonstrated the pivotal role of
effective, personalised care and support planning as a means to achieve the
aims of integration. The following ‘I statement’ illustrates this aim:

“If I have complex health and care needs, the NHS and social
care work together to assess my care needs and agree a single plan to cover all
aspects of my care.”