News and Comment

Here Endeth the 10th Lesson

Tuesday 12 November 2013

So, integration is the agenda item on the government’s priority list for health and social care this year. It was certainly very clear at the NCAS conference in Harrogate last month. It was difficult to find a session which wasn’t about integration.

As I sat listening to the (renewed) enthusiasm of speaker after speaker I experienced a sense of frustrated déjà vu. Frustrated, because despite the years of good intentions; local joint ventures; government incentives, and the sheer common sense of the move, we have yet to really achieve a universal integrated service.

There are pockets of excellent partnership working. There are examples of multi disciplinary teams working as one for the common outcome of better health and wellbeing, but I believe we have yet to see a system which offers a solution to all the issues and barriers which block the way to true integrated health and social care.

The present imperative to deliver integration plans by March 2014 to secure ITF funding, has made me revisit my own integration experiences in an endeavour to shed light on the essential elements necessary for integration arrangements to succeed. In doing so my intention is to support new initiatives to avoid the pitfalls and not repeat the mistakes of previous attempts.

My career in social care has put me at the heart of integrated developments for the last 15 years. I have designed and directly managed complex integrated commissioning and provision structures as well as supporting others in their own integration journey. I have been in the position of having to unpick arrangements where health and social care staff had become familiar with working as one organisation and have mediated in disputes between parties.

As a result of these earlier experiences I have created my 10 lessons learned. I will keep these in mind as we embark on our current attempt. I hope they are helpful to you too:

Integration is not an outcome

Developing integrated mechanisms and structures can become the overwhelming priority. It is worth a constant reminder that the process of integration is the means to deliver shared, agreed outcomes.

Trust is not enough

While trust is essential to a successful partnership, there has to be more than trust behind the partnership. There needs to be real, clearly stated objectives. Nurturing trust between strategic leaders will give the process an initial impetus and will enable smaller issues and challenges to be overcome, but strategic leaders change over time. Those who started the integrated arrangements may move on and others take up the reigns of leadership. The rationale behind integrated processes needs to be clearly communicated to new leaders, then trust will grow and take its place in the integrated tool kit.

Clear understanding of the obligations of all partners

Integrated arrangements often mean sharing of resources. It can mean delivering the core functions of other organisations. It can mean managing the funds of others. With rights come responsibilities. Such responsibilities must be undertaken with due diligence. It is important at the outset of any integrated arrangement that the partners are clear about the responsibilities that each have and understand how those responsibilities may be compromised by any shared enterprise.

Clearly defined outcomes for all partners

Defining what is expected at the outset of a joint enterprise seems like an obvious part of the process. However, it often gets lost in the imperative to be seen to be working together. It is only later when the unstated need for particular outcomes by one partner is not being met does it become clear that these were not articulated in the beginning. Be clear what the expected outcomes are for each partner. They do not have to be the same for each, but stating them at the beginning focuses the partnership on achieving outcomes for all and saves disputes later about what the nature and purpose of the enterprise was.

Integration must be ‘owned’ by all partners

An integration initiative which is one-sided or dominated by one party with other passive participants is unlikely to succeed. All partners must be clear that they have an active part to play in making the integrated arrangements work and that their active participation has benefits for their organisation as well as across the whole system.

Get buy-in from other stakeholders

Within a health and social care system there will be other stakeholders who, although they are not part of the partnership, will be affected by the new arrangements. Their response can be very influential in delivering the outcomes for the partnership. Some larger stakeholders can make it impossible for a new integrated arrangement to work if they believe their interests are not best met. Understanding what the consequences are for your stakeholders will make your new arrangements stronger.

Conflicting priorities require joint resolution

Once an integrated arrangement is in place any shift in the position of any partner needs to be dealt with as a joint issue. Open discussion about new priorities which may alter the standing arrangement is the surest way of keeping an integrated arrangement healthy.

Commit to seeking whole systems solutions

Issues which arise for one partner which may threaten the delivery of the integrated arrangement are more easily solved if the combined resource of the whole system is used to find solutions. One partner working on their own issues without the joint discussion is likely to miss unintended consequences for other partners. Such actions can lead to an inability to meet the agreed outcomes and the escalation of trust issues between parties.

Have clear governance arrangements

Be clear about where decisions should be taken and who can make decisions. Equally, ensure decisions are taken. There should be no room for ambiguity about what has been decided and when action will be taken.

Describe the fallback position

Some integrated arrangements are very complex. It is worth being clear what the alternative arrangement would be, because in describing the alternative separate system it becomes self-evident why the integrated arrangement is preferable. In times of strain within a partnership it is also helpful to see the benefits of finding a whole systems solution as opposed to unpicking the current structures and setting up new separate arrangements.

Of course, the key to delivering positive results from all these lessons is communication. Not just talking about what you want to do, but listening to each partner’s issues and challenges. It is important to raise awareness to the point where each partner comprehends the requirements and responsibilities of the others and works to ensure all partners deliver. At such a point we may have a truly integrated system.

At that point the individual user may truly describe, not ‘my health and social care’, but just ‘my care’.