Health And Social Care Integration is struggling in England. Increasing financial constraints on councils and NHS bodies are making it harder to achieve integrated health and social care, government-funded research has warned. The study also found that engaging frontline staff in initiatives to integrate care was proving challenging in a climate where they were “firefighting” to keep existing services running.
Health and social care were beset by an “integration paradox” in which the financial environment made it ever more important to integrate care but, at the same time, made it more difficult to make progress in doing so.
The findings came from an early evaluation of the integrated care and support pioneers programme, a Department of Health initiative set up in late 2013 to test new ways of integrating care for people who needed the support of multiple care services. The study, by the Policy Innovation Research Unit, assessed the initial 14 pilots from January 2014 to July 2015 and was largely based on interviews with 140 council, clinical commissioning group (CCG), NHS trust and voluntary sector staff involved in pioneers.
The pioneers started with ambitious visions to transform care in their areas for people with multiple long-conditions and frail older people by shifting services out of hospitals, reduce costs and improve people’s experiences of care. They had plans to use a wide range of initiatives to meet these objectives including multi-disciplinary teams, improved access to services, rapid response teams to reduce avoidable admissions, telecare and telehealth, increasing the use of community resilience and personal health budgets.
But the researchers found that over time their ambitions appeared to have become more limited and focused on “short-term, financially driven goals”, mainly around containing hospital admission and discharge costs. Also, the range of initiatives used had narrowed to setting up multi-disciplinary teams, improving care planning, creating a single point of access for services and using care navigators to provide people with information and advice on accessing care.
Interviewees identified a number of barriers to and enablers of integration. Most of the enablers were local factors. These included the relative simplicity of organisational structures, with the best arrangement perceived to be when a pioneer involved just one council, CCG and NHS trust with similar boundaries. The most important of the enablers was perceived to be staff involvement in integration initiatives and the extent to which they felt ownership over them.
However, the report found that professional boundaries and cultural differences between health and social care staff were also barriers to integration. Interviewees identified difficulties in encouraging staff from different professions to trust one another or to motivate staff to become engaged in integration initiatives when they were “firefighting” to maintain existing services.
Interviewees felt the cuts to local government and financial constraints on the NHS were limiting their ability to reshape services. For example, initiatives to develop communities’ resilience were undermined by cuts to services such as befriending services, lunch clubs and peer support. Also, the pioneers were not given dedicated funding, hampering their ability to initiate changes to services. Over the course of the fieldwork, researchers found that the balance between barriers and enablers were, if anything, shifting towards the former as the financial situation deteriorated.
“This was resulting in an ‘integration paradox’,” said the report. “Growing need and declining budgets provided an even stronger imperative for more effective integration. However, at the same time, this context made it more difficult to make progress.” The context increased the incentives for organisations to “defend existing roles and resources for fear of something worse” The research team has been commissioned by the Department of Health to do another evaluation of the pioneers programme running up to 2020.