James MacDaid, Public Affairs Officer for the College of Occupational Therapists discusses Integration of Care – Opportunities and Challenges. Follow James
The health, social care and well-being needs of many people are complex, interrelated and often long standing. People may require carefully planned, co-ordinated and delivered interventions from a number of different groups working together, such as in multidisciplinary teams (MDTs). Occupational therapists are usually at the heart of MDTs, delivering high quality care and making significant contributions in helping to improve people’s lives.
With the launch of ‘Devo Manc’ in February 2015, and the merger of health and social care for £2.7m in Manchester, and the £6 billion budget that went with it, the starter gun for large scale integrated care systems has been fired. Further integrated care systems in Cornwall under the Pioneer arrangements; other cities, such as London putting in requests to follow the ‘Devo Manc’ model; and the forthcoming Devolution Bill, underlines the momentum behind the new health and social care arrangements. The integrated care referred to in this article is very much focused in England, the other three devolved nations, especially Scotland, are at different stages of development.
Why is integrated care seen by many decision makers as such an improvement in delivering health and social care? Ultimately, it’s because services are often fragmented and delivered by separate agencies working independently, duplication is evident, and there are significant resource inefficiencies in the absence of whole-systems approaches. Critically, service users experience these problems most acutely. Their experience and outcomes can be undermined by the involvement of different professions and agencies appearing at different times, and are given little effective voice and participation in the determination of their treatment, care and support.
The need for integrated care is usually driven, shaped and influenced by different motivations that include:
(i) efficiency, and making the best use of scarce resources which is particularly important in the current financial context of unparalleled economic restraint in the UK
(ii) effectiveness, and developing co-ordinated solutions to often complex and sometimes cross border issues
(iii) responsiveness, to ground interventions through the participation and empowerment of service users and their representatives.
The opportunities that integration of care offers for health and social systems, and thus the occupational therapists that will work in them are many, but also in any new model, there are challenges to be overcome.
As an idea, integration is complex, contested and the subject of definitional variety. It can mean different things to different people because there is no consensus on what should be integrated. Confusion is rife because of the frequent use of other terms such as alliance, partnership working and collaboration to mean the same as integration.
So, the first challenge of integration is often to achieve some common understanding between different interests of its purpose and objectives. With ‘Devo Manc’ there is a structure in place, but because this is a local arrangement, what is agreed in Manchester is not necessarily what will work in other cities like London, or regions, like Cornwall.
Many challenges relate to boundaries and the difficulties associated with spanning, mediating and managing them. For instance, professional territories can lead to integration being impeded, while regulatory bodies with statutory duties and accountability arrangements could stifle rather than allow innovation.
Integration therefore involves managing these boundaries, assembling teams of professionals to negotiate common purpose, and to co-ordinate or co-produce interventions that more effectively meet the needs of service users, and provide more efficient solutions for public agencies particularly in times of financial difficulties. Occupational therapists need to ensure that they are in the forefront of shaping these teams, or play a leading part within them.
Potential lessons can be learned from the Scottish example of the Highland Partnership where in April 2012 1,400 adult community care staff from the Highland Council transferred to NHS Highland, along with an £88m budget for the first financial year, as part of an agreement to make the health board the lead agency for adult care and the council the lead agency for children’s services. The model is the only one so far in Scotland to have adopted the lead agency model – where there is a wholesale transfer of services – and the agreement was made ahead of the Scottish government’s legislative proposals for integration, but it does give some insight into further challenges that occupational therapists should be aware of.
The Highland model showed how being part of an integrated team will be the biggest daily change to practice for some occupational therapists. In addition, having a single governance structure and budget is also a major challenge of successful integration.
Turning Challenges into Opportunities
Integration faces many problems of learning and knowledge management and requires leaders, managers and practitioners to develop a new set of skills and competencies to be effective in this form of governance. Inter-personal skills to build trust and promote reciprocity; innovation and creativity and collaborative values to work constructively with others are just some of the values needed. At the end of the day, whilst structures and organisational arrangements may help and hinder integrated working, it is the talents and mind sets of those working within such services that will ultimately determine success or otherwise.
Good leadership is a key component to ensure the success of any integrated care model, and occupational therapists, with their experience, usually in integrated care models like MDTs, have a great opportunity to position themselves to shape any new models of care. The profession is in a unique position, they already have the competences needed, either working in MDT teams or through their breadth of training. This gives occupational therapists the ability to already transcend separated health and social care systems. Integrated care models will give occupational therapists great opportunities to consolidate their strengths and position as a profession that can more easily adapt, in contrast to other health professionals, and work in these new models of care.
Although there are challenges that integration of health and social care systems bring, there are many opportunities for occupational therapists to take advantage of that will raise the value and awareness of the profession in the eyes of health and social care stakeholders. The profession should engage positively with these new models of care and make themselves an indispensable part of them. We have the skills, we have the training and we have the attitude to make integration of health and social care a great success for us and, more importantly, service users as well.