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About this book

This timely and much needed text book provides a systematic assessment of recent policy developments across the UK and introduces the different models of integration which currently operate - from structural integration in Northern Ireland to health and care partnerships in Scotland. It examines the achievements of integrated working, showing how it can lead to improvements in the quality of services and access to services, as well as create cost efficiencies. It also considers barriers to integration and draw comparisons with experiences in the US, Canada, Australia and Europe to identify lessons for practice in the UK.

Supported throughout by case studies and a wealth of illustrative material - including charts and diagrams - this is key reading for students taking degree programmes and foundational qualifications in health and social care, or related degrees in social policy, health studies, social work and nursing.

Table of Contents

1. Introduction and Content

The integration of health and social care has become a constant policy ambition in the UK. Closer integration has become the goal of successive UK governments for over 40 years (Humphries, 2015, has become established as a contemporary priority and endorsed by the devolved administrations in Scotland, Wales and Northern Ireland). It has been noted that the imperative to integrate and transform has never been greater (NHS Confederation/Local Government Association, 2016). The Barker Commission (2014) on the future of social care noted the compelling case for the bringing together of health and social care and called for far better integration built around people’s needs and an alignment of the two systems of care. In 2015 much closer integration of health and social care was identified as one of the three major challenges faced by the NHS (Ham, 2015). The Nuffield Trust (2015) has identified five factors to pursue in improving UK health care, each of which relates to integrated approaches: the quality of care, new models of care delivery, older people’s needs, complex conditions and workforce development. In their five point plan for the UK government in 2014 the Royal College of Physicians noted the need to remove the financial and structural barriers to joined-up care for patients and argued that it should be easier for hospitals, GPs and social care teams to work together than separately and shared practice and outcomes should become the norm. It is a matter for discussion how effective the rhetoric has been in reality (Glasby, 2016) although governments have been introducing legislative measures to support and promote integration.
Deirdre Heenan, Derek Birrell

2. Development of Policies and Strategies in England

Policy development specifically related to the integration of health and social care has quite a substantial history, usually identified as going back to the 1970s. This process has normally been dominated by the UK government and the responsible government department, although some policy discretion was exercised by the Scottish Office, the Welsh Office and the Northern Ireland Office and local administrations. After 1999 policies produced by the UK government applied only to England although some of these ideas and strategies could still influence developments in the new devolved administrations.
Deirdre Heenan, Derek Birrell

3. Reshaping Integration in England

The period since 2012 has seen a remarkable move forward in the UK with integration put on a statutory footing and having an enhanced status following new legislation in England, Scotland and Wales. Two pieces of legislation in England were of significance: firstly, the Health and Social Care Act 2012, which introduced institutional changes, particularly Clinical Commissioning Groups and Health and Wellbeing Boards; and secondly, the Care Act 2014, which makes integration, cooperation, and partnership a legal requirement for local authorities and also for all other agencies involved in public care and including private and voluntary organisations. Innovations introduced included joint commissioning teams, sharing of information, pooled budgets, and combined approaches to a market (Local Government Association, 2015, p. 16). To reinforce the focus on joint working at a local level the NHS is no longer obliged to seek reimbursement for delayed discharges attributable to the local authority. The joint programme management scheme offered support in local areas on the implementation of the Care Act and associated reforms through case studies, templates, self-assessment frameworks, and tool kits. The major institutional developments impacting upon integration in England can be listed as: Clinical Commissioning Groups; Health and Wellbeing Boards; Healthwatch; and the new city devolution structure covering health and social care. The continuing significance of innovations, the Pioneer and Vanguard initiatives, the Better Care Fun, Sustainability and Transformation Plans, and the increasing role of inspection and scrutiny through the Care Quality Commission, audits, NICE, and more focused research and evaluation are assessed.
Deirdre Heenan, Derek Birrell

4. Integration in Scotland

In 1998 the new Scotland Act gave the Scottish government and Parliament control over health and social care, although the services had been administered in Scotland previously operated through the Scotland Office. The health system was based geographically on NHS boards but operated on a principle of collaboration and partnership and not on an internal market (Steel, 2013). Local government was responsible for adult social care and children’s care. Health care was predominantly provided by the public sector with a small private sector, but independent social care and support by private and third sectors increased sharply as in England. By 2012 some 88 per cent of care homes and 51 per cent of domiciliary hours were in the independent sector (Audit Scotland, 2012). The allocation of funding for health and social care was determined by the Scottish administration but from the overall allocation to Scotland from the UK Treasury.
Deirdre Heenan, Derek Birrell

5. Integration in Wales

With the establishment of devolution in 1999 health and social care policy became one other responsibility of the Welsh Assembly government. Health and health services and social services had the status in the then Welsh form of devolution as fields for executive action. Powers increased after the Government of Wales Act 2006 which allowed legislative competence over 20 specified subjects including health and social welfare which covered the social services, and the care of children and older people. Local government was also a specified subject. These powers involved a complex legislative system of measures requiring Westminster approval. In 2011 after a referendum the Welsh government assumed full responsibility for primary legislation within the 20 fields including health and social care. The services are both operated and managed by the Health and Social Care Department of the Welsh government. The devolved services were funded through the Barnett formula, as in Scotland and Northern Ireland, and with similar discretion over the allocation of devolved expenditure to health and social care. Wales has a tradition of a relatively small private sector and modest charges for community services.
Deirdre Heenan, Derek Birrell

6. Integration in Northern Ireland

Northern Ireland has had a model of structural integration of health and social services (social care) since 1972. It also has lengthy experience of devolution going back to 1921, although interrupted by a period of direct rule from Westminster from 1972 to 1999. Health and social care were confirmed as devolved matters in the new devolution legislation of 1998. Northern Ireland has chosen to follow closely the principles of the NHS and maintain parity with the rest of the UK in standards of health and social care provision. Thus, much of the framework of policies and strategies has been similar to Great Britain in terms of community care, purchaser-provider division, and GP fund holding, but this has not prevented some significant differences in administration and some policies. The long-standing commitment to structural integration has developed as one of the most comprehensive structured integrated systems for health and social services in Europe (McCoy, 1993).
Deirdre Heenan, Derek Birrell

7. Achievements of Integration

Identification of the achievements of integration of health and social care requires examination of a range of material which has focused on the outcomes of integrated projects and working. The evidence, which is now considerable, consists of policy and project evaluations, reviews, research projects, pilot studies, and case studies, and can be categorised as follows. Much of the early evidence on the achievements of integration tended towards two main conclusions: firstly, that much of the early evidence concentrated on the processes of intervention rather than the outcomes and, secondly, that there was a dearth of research evidence to support the notion that joint working between health and social services was effective (Cameron et al., 2000).
Deirdre Heenan, Derek Birrell

8. Promoting Integration

There has been an extensive analysis of the factors which have been identified as contributing to the promotion of integration. Such an analysis makes use of research and evaluation studies, policy analysis and reports and work by practitioners and professional bodies. Most of the analysis in this chapter relates to practices and lessons from experience in England. Relevant work related to the rest of the UK is discussed in the chapters on the devolved administrations. While it is possible to arrange the analysis into a few general headings, the categories can overlap or do not add much clarity in specifying the details of promotional factors. Therefore the chapter is organised under a wider number of headings based on the major factors under discussion as promoting integration.
Deirdre Heenan, Derek Birrell

9. Barriers to Integration

There remain a number of problems to be faced in pursuing the objective of implementing integration seen both in limited initiatives and projects and in more comprehensive strategies and processes. Their continuing significance is demonstrated in the use of the strong language of barriers and obstacles in discussions of the issue. There is more of a consensus on the nature of the main barriers than on the more diffuse identification of enablers of integration. In some instances it can be noted that the conditions and actions that promote integration are the reverse of factors that are identified as barriers (Wilkes, 2014). In other issues examined, the barrier may be of a more complex nature. Some of the clearer examples of barriers have been integrated partnerships which had to be ended because of a breakdown in delivering the intended objectives. Other barriers have been identified and addressed but with varying degrees of success.
Deirdre Heenan, Derek Birrell

10. International Perspectives

As noted in the introduction the NHS and social care services are entering a period of unprecedented financial challenges and the need to ensure that the system is efficient and effective is greater than ever. These are not, however, just UK issues, but international priorities and universal challenges. Irrespective of how systems are financed, organised and what services are delivered, gaps and inefficiencies exist, and greater cooperation, coordination, collaboration are core objectives in health care. While the definitions used, the strategies adopted and the extent of policy change vary across the globe, the underlying desire to create services that operate more efficiently and effectively in an integrated manner is strong (Dickinson and Glasby, 2009). A common understanding of integrated care has developed in Europe but has been criticised as being too idealistic with the reality often not living up to the rhetoric (Billings, 2005). Though widely acknowledged as a positive development producing favourable outcomes, Minkman (2012) noted that implementing integrated care is a complex, difficult task. While the commitment to integrated care has developed globally, outside the UK the main focus has been delivering coordinated care for older people with chronic conditions.
Deirdre Heenan, Derek Birrell

11. Conclusions

It is clear that there is a strong commitment by all governments in the UK to promoting the integration of health and social care, accepting the rationale for this policy, anticipating the benefits of integration, and supporting implementation of integrated practice. This policy has been endorsed at all levels of government including local government and non-departmental public bodies and is also strongly supported by advice, guidance, reports and analysis presented by representative and professional bodies. Closely associated with the adoption of a policy of integration has been the acceptance of another policy change, a shift in resources from acute care to community based care. Also implied is a change in the scale and functions of acute health care, the development of aspects of the provision of adult social care bringing closer together health and social institutions and also adopting change in commissioning structures and procedures, management and workforce development.
Deirdre Heenan, Derek Birrell
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