If integration is the answer – what was the question?

Professor Jon Glasby

Over time, governments of all persuasions have sought to achieve more integrated health and social care. This ranges from the Joint Consultative Committees and joint finance of the 1960s and 1970s to care co-ordination in the 1990s, and from New Labour’s emphasis on ‘joined up solutions to joined up problems’ to the Coalition’s promotion of ‘integrated care’. The latest version is a series of ‘integrated care pioneers’ (which the University of Birmingham helped to select), with learning from these sites shared with other areas of the country to promote more holistic care.

Despite all this, we continue to have a very divided health and social care system (even if we have found ways of blurring the boundaries from time to time). Deep down, our approach is based on the assumption that it’s possible – and possibly even desirable – to distinguish between people who are ‘sick’ (who we see as having ‘health’ needs met free at the point of delivery by the NHS) from people who are merely ‘frail’ or ‘disabled’ (who we see as having ‘social care’ needs met by local authorities and subject to means-testing and significant user charges). This may once have made sense – but feels increasingly unsustainable and counter-productive with an ageing society. At best, it causes frustration, duplication and inefficiency; at worst it can lead to people with complex needs falling through the gaps in the safety net which services are meant to provide. Whether it is child protection scandals, mental health homicides or older people discharged from hospital before community services are ready for them, the consequences of not working together can sometimes be catastrophic.

In response, the emphasis on ‘integrated care’ is welcome – but the problem is that this can mean so many different things to different people. It is also becoming something of an automatic policy response (just as ‘partnership working’ did under New Labour) – put forward as a solution to a range of different ills. All too often, this leads to a situation where we use warm words, but where everyone ends up frustrated because no one way of organising could ever deliver all the potentially mutually incompatible aims that individual partners may want to achieve.

As a result, a key contribution which HSMC when working with policy makers and front-line services makes is to ask: if integration is the answer, what was the question? Although this sounds basic, we need to know what we’re trying to achieve before we decide how best to go about organising our service responses. While some sort of co-ordinated effort may be required for some outcomes, a single agency working by itself might be just as effective for other issues. Being clear what success would look like is also a crucial first step to being able to evaluate ‘what works’. However, we often fail to do this – partly because public services have such multiple accountabilities that being clear about what success looks like is really difficult; but also (slightly cynically) because if we aren’t able to be clear about what success looks like, it’s also hard to be clear about what failure looks like. Joint working is also very time-consuming and it takes significant commitment to build long-term relationships. Reserving such a labour-intensive way of working for situations where it will have maximum impact feels crucial.

In the current financial context, it is even more important to work together than ever before – but calling something a ‘partnership’ doesn’t make it so. If we’re not careful, then concepts such as ‘integrated care’ could become an end in themselves, rather than a means to an end – and people using health and social care deserve more than this.

Jon Glasby is Director of the Health Services Management Centre (HSMC) and Professor of Health and Social Care.

For further information, see Glasby, J. and Dickinson, H. (2014) A to Z of inter-agency collaboration and his new book with The Policy Press on Partnership working in health and social care: what is integrated care and how can we deliver it?

Other useful links:

What is integrated care?

Integrated care: A position paper for the WHO

Integrated delivery networks: a detour on the road to integrated health care?

Patients need to be the focus of integrated health care


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