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INTEGRATED CARE
Integrated care – from whose perspective?
Integrated care is heralded as the way forward for health and social care services facing the increasing demands of populations who are living longer, and where increasing numbers of people are living with complex conditions. Mary Twomey, programme director for health and social care at the Open University, argues that in order to succeed, delivering integrated services involves challenging individual as well as organisational practice.
To
suggest that the integration of health and social care provision is necessary
is to risk understatement, particularly from the perspective of people with complex needs. Evidence from organisations such as National Voices reveals a picture of care that is fragmented, un-coordinated and often frustrating. Contrast this with evidence from projects where integrated care works well, and the argument for integrated services, at least from the perspective of users of services, becomes clear.
And the numbers of people with complex needs are increasing, of course. Over the next 20 years, the number of people aged over- 85 is expected to increase by over 100%, and the number of people living with multiple complex conditions is set to rise, a trajectory that requires a very different approach to the provision of healthcare, to one of acute hospitals providing in-patient care to large numbers of people with long-term conditions. If health services are to be sustainable, it’s clear that admission and re-admission rates need to fall, and services need to be delivered both effectively, in terms of outcomes for those who use them, and efficiently.
54 | national health executive Nov/Dec 14
To say that providing effective and efficient integrated services is a challenge, however, is also to risk understating the case. As Richard Humphries of the King’s Fund says on his blog, the most effective use of the Better Care Fund requires “collaboration across the whole system of health, care and support, engaging fully with all NHS, local authority and third sector partners”, and “a reduction in hospital activity and income”. This, he says, is “big, risky and hard to do” in terms of the tough choices required around resource allocation.
What’s also big, potentially risky and certainly hard to do is changing the day- to-day experience of those in receipt of care. The document that describes the vision of the National Collaboration for Integrated Care and Support identifies key principles, which to some extent describe the structures and working relationships necessary to achieve this vision. What it doesn’t do, however, is to pin down the fundamental problem that needs to be addressed for
integrated services to work routinely and across the board, and that is the lack of a common approach to care by those who are actually delivering that care, the people on the ground.
“It was too much for the community nurses, who felt that their
perspective was too different for them to be comfortable.”
That a problem exists is acknowledged by frequent references to the need for ‘culture change’, both at an organisational and an individual level. It is this culture change that is implicit in the King’s Fund’s call for the emergence of services to be ‘bottom-up’ as well as at organisational level. Unfortunately, though, it’s the organisational aspects of change that are easier to define: to incorporate into a vision and plan, and to subsequently evaluate. There is a danger that this
is where the focus remains.
Changing structures at national or at local level will not on their own deliver integrated care, or at least not if this is where efforts stop, without changing the starting points of those who deliver care services to those who
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