What can I do? Taking action to promote aligned, patient-centric services

In this blog, IPC Associate Director, Professor Keith Moultrie looks at how we can continue towards goals of integrated care and support, despite the huge capacity, resource and demand challenges our care services are all facing.  He draws on recent IPC work to consider the barriers in the way of more aligned, patient-centric services and discusses what is needed from local partners to address them.

The challenge of silos

NHS, local authority and independent care sector leaders, professionals and commissioners have always had to deal as best they can with fundamental differences between the structure of community health, social care and wellbeing services.  Different agencies have developed either independently or (at best) in parallel, instead of being able to take an integrated, collaborative approach across system boundaries. As a result we have built a hugely complex web of community services with different access criteria, charging arrangements, professional roles, service responses, communication systems and expectations on individuals and families.

In the last three years, with partners under huge demand, capacity and resource pressures, we have seen the desire for greater integration really challenged, and many defensive behaviours characterised by:

• Leaders and professionals wanting to differentiate between similar jobs, tasks and roles across the system, and to use this to protect terms and conditions or sometimes to blame the ‘failings’ of other partners.
• Boundary disputes, particularly over financial responsibility and liability, requiring a disproportionate level of management and professional time.
• An over-reliance on contracts and formal assessments to fix ongoing service delivery arrangements which do not recognise the day-to-day changes in need that people have, particularly those with long-term conditions.
• Limited responsibility and influence of patients and service users in the delivery and development of care.
• Continued heavy reliance on the acute health sector, making some interventions unnecessarily extensive and expensive.
• Management of demand through waiting lists and triage, with case-finding, recovery, early intervention and prevention playing a relatively small part in responding to need.
• A continued boundary between health and social care in the UK as a result of different funding regimes (most obviously in the charging for complex nursing and residential care) and complex, time consuming and stressful negotiations between the NHS, the individual, voluntary and family support, and local authorities in individual cases.

I have worked in this field for over 45 years as a practitioner, manager, researcher and advisor. I have lost count of the hundreds of workshops I have facilitated and meetings I have chaired to look at how partners in one local area or another in Wales, England or Scotland could move forward more effectively together. Some of these have produced practical and workable local solutions, but many others have got lost somewhere between policy, principles and practice, and gone nowhere. When partners have different ideas about what joint improvement priorities should be, and this difference is encouraged and legitimised through separate planning and performance management arrangements, it is no wonder that the behaviours described above emerge, and progress becomes slow or halting.

Of course some of the solutions here rest with the different UK governments who need to set the financial, resource and policy context to enable partnerships to thrive,  including through public sector funding; charging and social insurance arrangements for social care; recruitment and retention of staff; and the legislative and policy framework underpinning integrated services. We all hope that the new Governments across the UK will create sustainable national frameworks for improvement soon.

A focus on action

However, I suggest, given the unprecedented challenges faced now by health and social care across the UK, that we can’t wait ‘on pause’ for a national blueprint (whatever it looks like), and that it is now time for local partners to step up further, and focus together on dealing with the key local whole system changes that have the potential to make a real difference to the effectiveness of integrated community provision. Without such a local commitment (and even if there is new national guidance) partners will increasingly retreat from a whole system perspective, put up boundaries causing difficulties for their colleagues, and waste more time on wrangles about who, when and how people are supported.

If partners are going to be able to secure more effective care services through partnership they will have to operate together in real life as a single network – not a series of parallel but independent agencies. Leaders in the system will have to work together on a shared community care agenda, and professionals will have to do their particular jobs as part of a more integrated and cohesive wider team and network.

In practical terms, at IPC we think there are some key areas that over the years we have seen as crucial for partners to work on together:

• Use the care network as the basic design unit – not individual services, practices or professions.
• Create a common language and frame of reference which recognises the shared contribution to effective care across the network.
• Work together to develop the local care model that partners agree they are working towards.
• Build whole system care pathways across services rather than limiting them to traditional service boundaries.
• Work up joint and common population assessments and analyses of needs across health, wellbeing and care.
• Engage together with local people on the kind of care and support they want to see in the future.
• Work together jointly on common information systems, common staffing and workforce frameworks, performance monitoring and management.
• Develop integrated commissioning arrangements based on the community care boundaries so that partners are working on the same key service changes at the same time.
• Look to pool budgets and resources wherever this will create more flexible working between agencies.
• Move teams towards greater integration including through co-location, shared or single management of teams, place-based multi-professional services.

Practical solutions which enable collaboration

Of course it is likely that every local area in the UK has care partners who are working on some or all of the priorities above. However, where we have seen particularly successful community care partnerships, they have taken the idea of joint working really seriously. They have not allowed themselves to get stuck with a model of partnership involving autonomous agencies sharing information but operating in parallel – they have risked working together in a way on these issues which is characterised by shared responsibility for a shared single network.  Without this change in mindset, partners end up retreating under pressure to single service perspective, and the barriers go up.

One starting point for local partnerships is to build a shared model of what partners are trying to achieve together, to use as the basis for reviewing existing practice and agreeing shared priorities. The following is an example, originally published by IPC in 2020 of what that shared model and shared aspiration might look like:

It looks like we will see national policy from the different UK governments in the next few months which will all encourage further integration of community-based care services. Hopefully these will provide new platforms to enable local partners to move forward, but in the meantime there is a great deal that can be done at a local level to establish more integrated care in practice. Let’s not wait, there is much to do. As a wise person once said ‘Action removes the doubt that theory fails to resolve!’.