© University of South Wales

Going Against Nature:Integrated working across the sectors

Marcus LongleyProfessor of Applied Health PolicyDirector of the Welsh Institute for Health and Social Care

WCVA Conference, 9th July 2014

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The argument

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If you wanted sectors to cooperate you wouldn’t have…• Different funding mechanisms• Different charging regimes• Different accountabilities• Different training• Power imbalance• Minimal client control• New policies every five minutes…

But giving up isn’t an option

For citizens, lack of integration…• Provides support

– too late– haphazardly– disjointedly– bureaucratically– not at all

• Puts them in hospital unnecessarily• Keeps them there too long• Wears them out

It’s crazy!33

Forget altruism: what’s in it for us?

• Make hospitals more efficient• Reduce/delay dependency• Free up resources for the community• Greater role for 3rd sector• Please our clients/patients/voters• Could stave off future demand• Kudos• Make us feel good

• But it may well not save money overall

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So... What is Integrated Working?

‘the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money’

World Health Organisation (2008) Integrated Health Services - what and why? Technical Brief No.1

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Types of integrated care

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Type Description

Systemic Coordinating and aligning policies, rules and regulatory frameworks

Normative Developing shared values, culture and vision across organisations, professional groups and individuals

Organisational Coordinating structures, governance systems and relationships across organisations

Administrative Aligning back-office functions, budgets and financial systems

Clinical Coordinating information and services and integrating patient care within a single process

You know it when you see it

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Characteristic e.g.

Co-location Same bases

Integrated teams Shared accountability, shared processes

IT-integrated care Personal digital assistants, remote monitoring

Patient-integrated care Patients control information, commission services

Single assessment Common data, shared eligibility criteria

Single point of access Easy, obvious, simple, friendly front door

Clients get...

• No big gaps in care – ‘I am always kept informed and professionals talk to each other’

• Co-ordination – ‘I always know the main person who is responsible for my care plan’

• Shared and accurate information – ‘I don’t need to repeat information constantly and I can see my health and social care record at any time’

• Shared decision making – ‘I am always as involved in discussions and decisions about my care as I want to be’

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Integrated working to date

• Joint health, social care and wellbeing plans• Local Service Boards• Little joint budgeting• Few joint appointments• Locality networks in NHS (c50k population)• Some inter-local authority integration• New Social Services Bill

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But this is hard work...

1. Common cause, share sovereignty2. Shared narrative on why integration matters; persuasive vision3. Shared leadership4. Time and space to understand5. Identify those who will benefit most6. Build from top down and bottom up7. Pool resources; be realistic about costs8. Innovate (contracting/payment, use of new providers, workforce)9. Recognise there is no ‘best way’10. Support and empower users11. Share information about users12. Specific objectives and measure progress

Adapted from Kings Fund (2013) Making integrated care happen at scale and pace

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Taking stock… key planks

1. Organisational alignment

2. Alignment of incentives

3. Leadership

4. Control with patients/service users

5. Case management

6. Persistence

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Strengths•GP registration•Organisational stability•National chronic conditions work

Weaknesses•NHS/local govt dislocation•Risk stratification not embraced•‘Not invented here’ syndrome•Isolated pioneers

Opportunities•Integrated Health Boards•Locality networks•Focus on patient experience•Government commitment

Threats•Financial pressures•Acute hospital demand•Hospital reconfiguration

What can the Third Sector Do?

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• Insist on evidence and accountability• On the problem, causes, effectiveness, impact• From all parties

• Play the patient card• Do your own integration• Be an honest broker/catalyst• Bring alternative finance (NB social impact Bond)• Hang on in there• Be an AmeriCAN

The tipping point

'Da mihi castitatem et continentiam, sed noli modo’

"Give me chastity and continence, but not yet."

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Augustine of Hippo

When integration is clearly better than the status quo for a critical mass of clinicians, other professionals and managers:

• evidence• trust• burning bridge• professional aspirations, identity and competence• leadership

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Further reading

Armitage GD, Suter E, Oelke ND, and Adair C (2009) ‘Health systems integration: state of the evidence’ International journal of Integrated Care 9(17) 1-11

BMA Health Policy and Economic Research Unit (2012) Integrating Services without Structural Change London: BMA

Fulop N, Mowlem A and Edwards N (2005) Building Integrated Care: Lessons from the UK and elsewhere London: NHS Confederation

Kodner D (2009) ‘Altogether now: a conceptual exploration of integrated care’ Healthcare Quarterly 13(Sp) 6-15

Leutz WN (1999) ‘Five laws for integrating medical and social services: lessons from the United States and United Kingdom’ Milbank Quarterly 77(1) 77-110

RAND Europe and Ernst and Young (2012) National Evaluation of the Department of Health’s Integrated Care Pilots Cambridge: RAND Corporation

Robertson C, Baxter H, Mugglestone M and Maher L (2010) Joined up care NHS Institute for Innovation and Improvement

Shaw S, Rosen R and Rumbold B (2011) What is integrated care? An overview of integrated care in the NHS London: Nuffield Trust

World Health Organisation (2008) Integrated Health Services - what and why? Technical Brief No.1

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© University of South Wales

Thank you

Marcus.longley@southwales.ac.uk01443 483070 http://wihsc.southwales.ac.uk/