Glasby, J., Dickinson, H. and Miller, R. (2014), "No one ever said it was going to be easy: the importance of people and relationships in creating integrated care", Journal of Integrated Care, Vol. 22 No. 5/6. https://doi.org/10.1108/JICA-08-2014-0032
Emerald Group Publishing Limited
No one ever said it was going to be easy: the importance of people and relationships in creating integrated care
Article Type: Editorial From: Journal of Integrated Care, Volume 22, Issue 5/6.
Anyone trying to work in partnership with others or to deliver more integrated responses to need knows that the key issues are around people, culture and relationships. And yet, so often the debate about integrated care is dominated by issues of organisational structure. In the NHS, this takes the form of regular organisational upheaval every few years – almost as if the perfect organisational structure exists, but that we just haven’t found it yet (since 1948). In integrated care circles, the same debate often plays out in terms of aspirations for more formally integrated organisational solutions (whether this is “Care Trusts” in England in the early-mid 2000s, New Labour's integrated care organisation pilots or more recent debates about “accountable care organisations”).
Despite this, the papers in this edition of the Journal of Integrated Care offer a different perspective, recognising that delivering truly joined-up care and support is messier and harder than this. The issue starts with a paper from Helen Dickinson, who argues that the tendency to conceptualise the study of integration in a “scientific” way has led us to lack insight into the sorts of factors that actually make integration “work”. Drawing on the broader literature of governance studies, Dickinson argues for the importance of acknowledgeing “craft and graft” as important factors that drive integration. This, of course, has implications for how we understand and study integration, but also the ways in which we support, develop and educate professionals who we are asking to deliver integration.
If there was a simple organisational solution, the chances are we’d have found it by now. While Northern Ireland is often held up as a beacon of good practice in this respect, the reality at ground level is inevitably more complex. Against this background, Derek Birrell and Deirdre Heenan, longstanding commentators on integrated care in Northern Ireland, review the recent advent of integrated care partnerships (ICPs). With limited powers and an unclear relationship with current structures, there is a danger that ICPs focus on the integration of different aspects of health care (thus making the further integration of health and social care even harder). At face value, this seems proof of one of the “five laws of integration” (Leutz, 1999), that “your integration if often my fragmentation”.
In addition to experience from Northern Ireland, the model of Community Mental Health Teams (CMHTs) is a longstanding innovation that has become part of established service provision – perhaps leading us to forget the initially innovative nature of this service model and to neglect potential lessons. In our next paper, Michele Abendstern and colleagues review the CMHT model and argue that broader issues such as nurturing team environments, the need to be fully resourced and support for integration from managers appear to be more important than structures per se.
Public health is another area where we have substantial experience of trying to work in cross-cutting ways on complex problems (but again where there may be scope to learn more lessons around integration than we have so far managed to do in practice). Building on a key national study of public health partnerships, Neil Perkins and David Hunter are clear that:
Structures are less important than relational factors such as trust and goodwill. More effort needs to be placed on developing robust and sustainable relationships than on structures and process (Perkins and Hunter, 2014, p. 222).
They also see ongoing re-organisations as “partnership killers” – with many of the national policy “solutions” to the issue of silo-based services sometimes making things worse rather than better. If new Health and Well-being Boards learn anything from the past, it is that they need to avoid the dangers of relying on structural, overly engineered approaches:
How “wicked issues” can best be tackled suggests the need for a different approach to partnership working that is looser, more flexible and responsive to rapidly changing contexts, and, above all, less engineered. Too often, if partnerships are not seen to be working, the temptation is to resort to yet more structure or to adopt a mechanistic response by proposing that the partnership should give greater emphasis to a more target-driven approach, or by strengthening monitoring arrangements to ensure that the partnership delivers what it promises (Perkins and Hunter, 2014, p. 226).
While structural “solutions” often focus on health and social care integration, such an approach neglects the relationships that health and social care need with multiple partners in order to be effective. Thus, Mike Clark explores an in-depth case study of joint working between the arts and care services, offering a new framework to understand such innovations in greater detail. By considering the appropriate level of intervention and the need for different relationships over time, this paper adopts a much more nuanced approach than many of the “one size fits all” structural solutions that are sometimes proposed.
Similarly, Jill Stewart and colleagues explore a series of broader relationships involved in supporting older people to age in their own homes, bringing in a vital housing and community component to debates too often dominated by health and social care. As this paper argues:
In order to facilitate more effective partnership working, developing an understanding of what Rittel and Webber (1973) refer to as “wicked” problems – or “messes” in Ackoff's (1974) parlance – may be useful. “Wicked” problems tend to have many interlocking causes and multiple stakeholders; they are hard to define, immune to “right” answers and thus resistant to “one size fits all” solutions. To make matters worse, attempts to implement a solution may inadvertently exacerbate the problem as stakeholders may have different perspectives and competing needs which cannot be satisfied by a neat and tidy solution. Viewed against this definition, ageing in place is clearly a very “wicked” issue.
Managing the needs of ageing in place, addressing the housing, health and social care needs of those with early onset dementia and whose condition will invariably decline, with or without support from family or community, is undoubtedly a “wicked” issue. As such, it requires holistic thinking, a greater understanding of the issue and those affected by it, and how they are affected by it. However, such thinking demands a very different kind of leadership that not only promotes collaboration but also fosters trust across a range of organisational stakeholders […] (Stewart et al., 2014, pp. 244-245).
In our final paper, Pam Moule and colleagues highlight the importance of a personalised approach to supporting carers, with different families in different circumstances wanting to design support in different ways. By definition, a standardised structure or approach could never hope to respond appropriately to such diversity – and the broader personalisation agenda is a classic example of the need to focus on relationships and on individual choices and preferences, rather than on organisational “solutions” or on formal structures.
As always, we hope these contributions are helpful to practitioners and policy makers trying to develop more joined-up responses to need, as well as to researchers trying to understand what works and to share lessons learned in order to improve future policy and practice.
Jon Glasby, Helen Dickinson and Robin Miller
Ackoff, R. (1974), Redesigning the Future: A Systems Approach to Societal Problems, Wiley, New York, NY
Leutz, W. (1999), “Five laws for integrating medical and social services: lessons from the United States and the United Kingdom”, Milbank Memorial Fund Quarterly, Vol. 77 No. 1, pp. 77-110
Rittel, H. and Webber, M. (1973), “Dilemmas in a general theory of planning”, Policy Sciences, Vol. 4 No. 2, pp. 155-169