Integrated working in the public sector
1 Sep 2014
Linda Miller, Senior Research Fellow
There has been interest in integrating health and social care services for over two decades, but it is only in the past few years that real progress has been made. The Health Act provides the accountability structure for a single Executive Leadership Team, pooled budgets and common goals. Interest has been sharpened firstly by funding of the Integrated Care Pilots in 2009, and more recently through the Better Care Fund announced by the Government in the June 2013.
The movement of responsibility for public health (and funding for this) to Local Authorities has also increased attention on the need for integration of health and social care. In other areas of public life too, the potential is being recognised for increased effectiveness – and, importantly in this time of budget constraints, greater cost-effectiveness – arising from joined-up services focused on the need of the individual.
The Better Care Fund (BCF) is a £3.8bn single pooled budget to support health and social care services to work more closely together to deliver better outcomes and greater efficiencies through more integrated services for older and disabled people. The NHS is expected to make a further £200 million available in 2014/15 to accelerate this transformation.
However, a pooled budget will necessarily lead to changes in how services are organised and delivered in future. As it is still relatively early days, only a minority of Local Authorities has attempted integration to date. For this reason the Local Government Association (LGA) commissioned IES to undertake four case studies of integrated services. These were designed to serve as learning resources and contribute to current thinking about the major questions involved in taking forward an integrated approach. Three of the cases focus on health and social care to improve support for elderly people or people with long-term conditions, while the fourth looks at a wider alliance of organisations focused on improving response to and reducing the numbers of incidents of domestic violence.
Better Together in Dorset, Bournemouth and Poole
Dorset County Council, Bournemouth Borough Council and the Borough of Poole joined with the NHS to find new ways to deliver health and social care services using funding won through the Challenge Fund. While the planned changes were prompted in part by the government drive to join up health and social care, they build on several previous initiatives within Dorset that have sought to join up services, including: the Partnerships for Older People initiative; merging of the Adult Learning Services across Dorset; and the integration of health and social care service provision for people with dementia. This earlier work built a partnership between the statutory and voluntary sectors, and the Better Together programme builds on those earlier experiences, with the local authority and NHS working with the Voluntary Sector Collaborative to deliver improved community support for residents.
The integrated care provision is based on a locality model. It is anticipated that there will be 13 integrated locality health and social care teams operating across Bournemouth, Dorset and Poole. Each patient or client will have one member of the team assigned as their care co-ordinator. The integrated care teams will merge the professionals and roles of existing services into one multi-disciplinary team with teams including GPs, community matrons, primary care practice nurses, physiotherapists, district nurses, occupational therapists, community mental health teams for older people, social workers and care managers, support workers and a voluntary sector coordinator, along with an administrator.
Betty Butlin, Service Manager, Older People and Physical Disability, said: ‘Part of Better Together is to look at how you can best provide the service. The Integrated Model reduces duplication and gives the service that is needed. We are all looking now at how we can work more succinctly together.’ The approach is starting to show results. Christopher Beale, Chief Executive Officer, Poole Council for Voluntary Service, has noted a shift from reacting to issues to being proactive: ‘For example identifying people in hospital who could be effectively supported to return home before they become too dependent. And in addition, close attention is paid to the impact of the service from the start.’
Integrated care in North Norfolk
North Norfolk was one of the original Integrated Care Pilots (ICPs) and has used the experience gained in that earlier work to build an integrated and co-ordinated model of care focused in four community hubs, centred around GP practices. John Everson, Head of Integrated Commissioning said ‘The ICP gave us a sense of the need for local area co-ordination across the system. So it was a starting point in building a strong integrated care foundation and it allowed us to identify what we needed to do next.’ In fact, John’s post is a joint appointment across North Norfolk Clinical Commissioning Group (NNCCG) and Norfolk County Council.
As well as this joint appointment, Integrated Care Co-ordinators have been introduced, based in the two integrated community team offices along with nurses, social workers, occupational therapists and GPs. The team see co-location as being particularly helpful in bringing about team integration and the ICCs are seen as an essential part of the mix; Becky Cooper, Assistant Director for North Locality, Norfolk Community Health and Care, said: ‘The Integrated Care Co-ordinators have transformed how we do things, they are the cement, really, a massive help.’ The team can already see improvements. Becky said: ‘Patients need to see fewer people. It’s streamlining patient care and there’s more we can do as a result.’
Another key part of the North Norfolk approach is to identify those patients most likely to benefit from an integrated care review: this is called risk profiling or ‘risk stratification’. NNCCG, in conjunction with one of the GP practices, developed its own risk-profiling software; this, together with use of GPs’ clinical knowledge of their patients’ needs, is the basis for interventions. Dr James Gair, Integrated Care Clinical Lead, NNCCG, said: ‘the combined clinical and professional expertise of GPs, community nurses/matrons, social workers and community mental health staff is used to help identify those patients who will most benefit from an integrated care discussion. These discussions then help to identify the most suitable support and services for that individual’s health and care needs. The value of this kind of integrated approach cannot be underestimated.’
Integrated Safeguarding and Public Protection in Wigan
The Wigan Building Stronger Community Partnership recognised the need for an improved multi-agency response to incidents of domestic violence and, as a result, the Local Authority and its partners developed an Integrated Safeguarding & Public Protection Team based on the principles of a Coordinated Community Response Model. At the core of this is a fully integrated team comprising members of the police, local authority, probation, fire service, housing and health services. Detective Inspector Mick Montford leads the team and he too is an advocate of co-location to improve integration; however, he notes that while co-location is important, on its own it’s not enough. “There is an important difference between co-location and integration. I didn’t want all the police, for example, to sit together in one corner. I deliberately mixed people up because I wanted them to get used to that and the idea that we will work as a team. Ensure a good mix-up and help people get used to each other.” Sarah Owen, Strategic Business Manager, Domestic & Sexual Violence, designed training for the team. She argues that: ‘Domestic Abuse is everybody’s business.’ People saying “It’s nothing to do with me” is completely wrong.’
When the case study interviews were conducted, the new arrangements had been in place for only 12 months but already the impact of the changes was being seen. The integrated approach has improved and developed staff awareness and understanding of a wider range of issues, for example around the impact of domestic abuse on children. Andrew Roberts, Operational Manager, National Probation Service, said ‘The holistic approach has unquestionably improved how we assess risk and subsequently manage that risk contributing to the safeguarding of victims within the local community.’
Integrated health and social care for the elderly in Salford
In common with the rest of the UK, Salford has a growing elderly population, predicted to increase by 22 per cent by 2030. Salford is committed to finding new and better ways of providing services and so for the past two years, health and social care partners have been working together to look at new ways of caring for and supporting older people in the district.
While the focus on older people is relatively new, Salford has a long history of strong health and social care partnerships, starting 12 years ago with integrating services for people with learning disabilities. This case study explores the ways in which Salford has approached integrating services. A central plank of its philosophy is the focus on individual patients. Jennifer McGovern, Assistant Director Integrated Commissioning, Salford said ‘There needs to be a focus on improving people’s lives. The vision is important. “We’re all in this together” needs to be the approach’. Dave Clemmett, Assistant Director, Operations, Salford, backed this up, saying: ‘You have to constantly talk about being person-centred and do this through collaboration with colleagues.’
To help in optimising and maintaining individuals’ overall well-being, Salford adopted an approach it calls ‘Sally Ford’, an approach to Integrated Care Planning based on six elements:
- a systematic assessment of health and social care needs;
- appointment of a named key worker;
- joint working with all organisations/ agencies involved, multidisciplinary groups and a single entry/contact point;
- an agreed Shared Care Plan, based on joint working and a 1 to 4 stepped level of care need (these levels are the ‘Sallys’ in the approach’s title);
- the sharing of essential information between provider agencies;
- and regular reviews to reconsider need and change plans as necessary.
All four project teams were seeing improvements to services even though it was early days. They are confident that the emerging data will demonstrate real cost benefits over the next few years. It is to be hoped that these examples will help other local authorities to take forward the integration agenda.
- The full-length case studies can be found here
 The Integrated Care Pilots programme was a two-year Department of Health initiative between 2009 and 2011 that aimed to explore different ways of providing integrated care to help drive improvements in care and well-being. A total of sixteen projects were funded across England.