“Buzzwords abound in healthcare. The latest, ‘Integration’, will only be achieved by effective collaboration across all boundaries; ‘partnership working’, ‘joint working’ and ‘joined-up thinking’ we have heard so much about for so long,” says Shirley Cramer, CEO of the Institute of Healthcare Management (IHM)."
Integration has been an overt policy goal of governments over the last two decades. We are told that it holds the promise to deliver real change. It will meet the growing need for long-term support resulting from changing demographics, shift from a hospital-based medical model to a social approach that keeps people in the community and maintains wellbeing, address so-called bed-blocking and save money - not necessarily in that order. Prior to the May 2015 General Election in the UK, it was clear that the concept of integration had renewed its grip on the imagination of the politicians. Amid claims and counter-claims about in which party’s hands the National Health Service (NHS) was safest, there was at least consensus that health and social care integration was the way forward.
In this area England lags behind Northern Ireland, which has 45 years of experience of an integrated system, and the other regions of the UK also have a way to go to catch up. The Welsh Government introduced an Intermediate Care Fund in December 2013 to drive forward integration between health, social care, housing and the voluntary sector, while Scotland’s Public Bodies (Joint Working) (Scotland)
Act, which introduced a requirement on NHS Boards and Local Authorities to integrate health and social care, was granted royal assent on April 1, 2014.
But England is also forging ahead with plans to make integration a reality. The 5.3 billion pounds Better Care Fund (formerly the Integration Transformation Fund) was announced in the June 2013 spending round with the aim of creating “a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services” (NHS England 2015).
In November 2013, 14 Integrated Care Pioneers were selected to demonstrate the use of ambitious and innovative approaches to deliver person-centred, coordinated care and support. Learning, we are promised, will be shared.
Meanwhile, no discussion of integration would be complete without mention of the announcement in February this year of Greater Manchester and NHS England’s plans to bring together decision-making on health and social care, combining total budgets of 6 billion pounds. The move saw NHS England, 12 NHS Clinical Commissioning Groups, 15 NHS providers and 10 local authorities agree on an integration framework for health and social care, designed to support and improve the population’s physical, mental and social wellbeing.
So the holy grail of integrated care is being hotly pursued, despite its many challenges and evidence that it doesn’t always achieve what it sets out to do. In an article in The Guardian (Bamford 2015a), Terry Bamford, author of A Contemporary History of Social Work (Bamford 2015b) notes that in Northern Ireland integration has failed to address a reliance on hospitals and institutional care, which is significantly greater than elsewhere in the UK. A model based on community-based services, he says, “remains an aspiration”.
Looking ahead, he adds that there are important lessons to be learned: “Structural integration, as in Northern Ireland or the short-lived experiment in England with care trusts, will not in itself deliver the change. Instead it diverts managerial attention to organisational change rather than developing
The Challenges of Collaboration
Yet collaboration is not always simple to achieve. In his Centre for Health and Public Interest 2013 paper Competition and Collaboration in the new NHS, Professor Bob Hudson, Visiting Professor in Public Policy at the University of Durham, described partnership working as “a delicate plant based upon shared vision and high-trust relationships”. In coming years, he predicts that we may witness “at best” guerrilla warfare as public sector commissioners and providers seek ways of working together more closely “in the face of legislation and regulations that pull in the opposite direction” (Hudson 2013).
Whether or not this prediction comes true remains to be seen, but it is difficult to see that anything other than closer collaborative working between providers and commissioners can deliver the dream of integrated health and social care. For the hard-pressed NHS – and in the best interests of patients – IHM would argue that this has never been more important.
In a 2007 literature review, Working in Collaboration: Learning from Theory and Practice (Williams and Sullivan 2007), the National Leadership and Innovation Agency for Health Care in Wales noted that the effectiveness of collaboration and partnerships as ways of managing and delivering public policy had been questioned in academic texts (eg, Sullivan and Skelcher 2002), in officially sponsored evaluation studies (eg, Williams et al. 2006), and by practitioners and managers on the ground.
A range of problems associated with making collaboration and partnerships “work” were identified. These included: leadership styles, multiple accountabilities, governance, cultural and professional differences, power disparities, differing performance management arrangements, institutional disincentives, historical and ideological barriers, resource problems and converting strategic intent into effective implementation.
The hurdles identified are not insurmountable, but clearly collaboration is not achieved simply by a belief in its virtues. In its report, Hospital Collaboration in the NHS: Exposing the myths (Fenton and Custance 2015), KMPG offered eight pointers to successful collaboration that could be applied in and across all health and social care organisations:
Design the solution to match the problem - the form of collaboration should match the goals and challenges of the institutions involved and the needs of the local health economy;
Prioritise sustainability over shortterm financial aims;
Ensure that both parties have something to gain;
Remember it’s all about the patient;
Engage and communicate with staff;
Don’t underestimate the importance of culture - leaders need to understand cultural similarities and differences in order to address divisive sensitivities and hence ways to suit all parties;
Standardise and codify good practice;
- Align payments and incentives.
In an environment that is increasingly made of markets and subject to competition, there is a risk that silo working may become a default position. In his book Silos, Politics and Turf Wars (2008), Patrick Lencioni warns: “Silos – and the turf wars they enable – devastate organisations. They waste resources, kill productivity, and jeopardise the achievement of goals.” IHM believes that a culture of collaboration should be encouraged across all healthcare boundaries. It may not be an antidote to every healthcare policy problem, but successful health and social care integration is impossible without it.