Integrated Care: an impossible dream?
Robin Miller, Senior Fellow at Health Services Management Centre
It’s been a busy few months for integrated care, with a raft of initiatives including the launch of the National Collaboration, the Better Care Fund and the new knowledge exchange portal. Collectively these can be seen as a national declaration of belief in the potential of integration between health, social care and wider community services. For those of us who have worked, researched and led integrated care it is undoubtedly rewarding to see its importance being so recognised, promoted and supported. Whilst integration (or in other guises such as partnership, joint working or collaboration) is not a new policy intent as such, there was a time in which it appeared to be falling out of favour in the current reforms. Much credit should therefore go to the Future Forum for firmly placing it in back on the agenda.
Our collective belief in integrated care often starts with an intuition that different professions and organisations working together must be more effective than them pulling in opposite direction. Such intuition is generally supported by the realities of working in settings in which promising initiatives or practices have been undermined through different expectations, priorities and processes. Most powerfully though, most of us will also have observed or indeed directly experienced the inadequate care that patients and service users suffer as a result of duplication in processes, poor communication and gaps between services. The problems caused by fragmentation at an operational and strategic level are clear to all.
Recognising a problem though does not mean that trying to do the opposite is necessarily an effective solution. To paraphrase Leutz, integration can also lead to fragmentation if the services concerned become more distant to other relevant provision. There are many different forms of integration in relation to the depth and breadth of connections and the types of linkages and incentives that they deploy, and what works in what context may not transfer well elsewhere. Outcomes are often not clearly articulated leading to an incomplete understanding of what has actually been achieved. And finally, there is always the danger that an integrated initiative which begins to deliver will be disrupted or disbanded through competing pressures, restructures or changes in policy direction.
How are we to proceed then? We cannot afford to ignore or underestimate the damaging impact of current and emerging fragmentation in our health and social care system, but experience and research tell us that we need to be more sophisticated and focussed in selecting our priorities for integration and how these are achieved. The usual suspects of successful change will be required, including strong leadership, shared acceptance of risk, willingness to learn and the confidence to try something new. Whilst there are reasons to be pessimistic there is also much cause for optimism and we have to hope that the mid-2010s will be remembered as the time when the integrated dream became reality…..if not, then we have to make sure that as a minimum it was the time when we developed an evidence base and shared set of skills to make this dream come true in the future.
Read the full Policy Paper 17 ‘Is integration or fragmentation the starting point to improve prevention?’.