Background:
The integration of community health and social care services has been widely promoted nationally as a vital step to improve patient centred care, reduce costs, reduce admissions to hospital care and facilitate timely and effective discharge from hospital (Barker 2014; Department of Health 2008). Precisely what this means in practice is less clear: integration can be defined at team, service and organisation level and involving different combinations of services (Stokes, Checkland, and Kristensen 2016). It can also be defined as outcome based, measured through the impact on the individual receiving care, or process based, measured through the change to the system delivering care (Robertson 2011). Questions remain about the practical challenges of integrating health and care given embedded professional and organisational boundaries in both sectors.
This study examines a single partnership organisation, established in 2018, formed around twelve integrated neighbourhood teams across a major English city, combining and co-locating community health and social care professionals. This study draws on a process evaluation commissioned to inform integration, specifically of community health and social care at this neighbourhood level in the city, to examine the contextual enablers and obstacles to integration in practice.
Method:
Across three localities 24 face to face semi-structured interviews were conducted to investigate the perspectives and experiences of staff involved in the integrated organisation. Eighteen interviews were conducted with those delivering services as part of an integrated neighbourhood team including; newly qualified to experienced staff in leadership roles and equal numbers of health and social care professionals. We also gathered contextual information by interviewing six strategic level staff with equal numbers from a community health and social services background. Sampling was purposive for maximum variation. Data collection was informed by a rapid scoping review of the UK integration of health and social care literature. Data were transcribed verbatim, organised in NVivo 11 and analysed using thematic analysis to identify key enablers and obstacles to integration while drawing on the contextual factors.
Results:
For all staff, at operational and strategic level there was a widely shared understanding of what integration should mean. Despite concerns about the integration process and the acknowledgement of widespread challenges, there was a general conviction that integration would benefit those using community health and social care services and the professionals involved in delivering those services. Staff were less convinced about the attention paid to the detail of integration and the practicalities, some arising from the fundamental challenges of different funding models and conflicting professional approaches, priorities and accountabilities. These concerns were underpinned by a feeling that community health had been underfunded and held in lower regard historically compared to acute hospital health services; social services were also felt to have been underfunded and now dominated by the much larger community health services. These tensions had specific implications for a range of team-related issues.
Implications:
Given the long-term policy focus on integration of community health and social care at a national and regional level these findings raise a number of implications for health and social care professionals, leaders, policy-makers and those accessing services. The united, positive vision of integration and the perceived benefits to those needing health and social care in the community was tempered by a lack of confidence about how the integrated teams would work in practice. Conflict around professional identity and boundaries continues to present challenges although there is wide anticipation this will improve through inter-professional working. Although there was a strategic level view that distributed leadership means teams will be encouraged to make decisions locally, operational staff views did not reflect this. In particular, this sheds light on some of the more intractable tensions which are central to the integration of health and care and opens up a discussion of the balance between top-down and bottom-up change in this context.
References:
Barker, K. 2014. “A new settlement for health and social care.” The King's Fund.
Department of Health. 2008. “High Quality Care For All.”
Robertson, H. 2011. “Integration of health and social care. A review of literature and models. Implications for Scotland.” Royal College of Nursing Scotland: 1-42.
Stokes, J., K. Checkland, and S. R. Kristensen. 2016. “Integrated care: theory to practice.” Journal of health services research & policy 21(4): 282-85.
