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Copyright © 2016, Emerald Group Publishing Limited
The value of values
Values are a familiar concept to all of us working within health, care and housing support. At the outset of our career, it is often a personal commitment to supporting others that is a key motivation for embarking on such a path. Once qualified, a willingness to uphold the values of a profession is core to our registration as a clinician or practitioner. And every day we use values to inform our decision making, particularly in situations in which there is not an agreed protocol or previous experience. They also influence our emotional wellbeing, with new service directions in tune with our values feeling energising and enriching and the opposite response for changes that seem to be in conflict. Despite their centrality we are often guilty of not spending sufficient time reflecting on our values and being clear about what we see as important, both about how we do our work and the expected outcomes. As a consequence it can be difficult for others then to understand how we react within certain situations. This can be complicated, as our individual values are shaped by a wide variety of potential influences including our society, our family and our faith or politics beyond those aligned to our professional code. We are also expected to practice within an organisational culture which will have its own espoused and implicit values and which may or may not be in harmony with our own beliefs.
The inter-professional working at the heart of integrated care is a dynamic which commonly brings values to the fore. Encountering alternative perspectives on how best to support an individual, to allocate resources or to address key conflicts can display subtle but important differences in understanding and priorities. Much of the related cognitive and emotional work is completed within the structure of teams, with a successful team allowing and indeed encouraging its members to express difference and resolve alternative perspectives openly. Value synergies or conflicts are also experienced at the partnership and policy-making levels, with considerable evidence regarding the importance of cultural fit between organisations involved within collaborative ventures. The overall benefits (or public value) of an integrated venture is a further area of debate. Values are therefore a core part of many of the emerging competency frameworks for inter-professional working, and there are new schools of leadership and practice-based around their importance.
The articles within this edition of the Journal of Integrated Care reflect the centrality and dynamics of values. Andrew Muirhead and colleagues report on a local initiative addressing the often described challenges regarding integration across the information systems held by different organisations responsible for providing health, care and support. One of the first issues to be overcome was how organisations could uphold their commitments to confidentiality of personal information which was central to their relationship with their patients and service users. Only once this was addressed could they move onto more technical issues relating to the processing of data, the segmentation of populations and the use of the combined data set in decision making. One of the key learning points from this programme was its approach to leadership and in particular the encouragement of distributed leadership with communities of practice to facilitate the sharing of experiences and insights. A responsibility for the system rather than their individual organisation was one of the key necessary values that emerged through the work.
In recent years, Scotland has been at the forefront of embedding integration within its national policy and legal framework, and has sought to deploy value-based political leadership in the development of these arrangements. The paper by Lynne Manne provides primary research on the experience of health and care staff within these new arrangements and in particular their role in discharge arrangements within community hospitals. Despite the national encouragement and requirement for more integrated working, these staff report a series of fundamental barriers in the system that prevent people received timely and co-ordinated care. These included – a shortage of resources and capacity, silo working across organisations and sectors, and a perceived lack of influence of frontline practitioners. These difficulties highlight the challenges of delivering policy aspirations on the ground, with the experiences of these staff in contract to the espoused values of the new national approach. One of the greatest sources of staff dissatisfaction and disengagement is an apparent clash between the values that are promoted (and which they would endorse) and the values that appear to actually inform decision making.
England provides an example of a different dynamic in that a key national policy direction is seen by many as being in conflict with how they believe a health and care system should operate. The issue in question is that of competition between providers, with successive English governments seeking to open up NHS clinical health services to market pressures. This has led to considerable outcry from many quarters with the approach being seen to clash with how services should work (in collaboration rather than competition) and what the end value could be (public good rather than private profit). James Fuller presents a “grass roots” perspective of the experiences of rough sleepers in London which critiques this and other aspects of recent legislative changes in England. His observations are that there has been to “further marginalise the marginalised” through a “shift in focus from the communal to the individual; the dilution of patient, public involvement due to the ‘professionalization’ and increased ‘marketization’ of health commissioning; the greater responsibility for public health vested in local authorities; and the further decoupling of health and social care”.
Next, Michelle Abersten and colleagues research the contribution of the voluntary and community sector to care coordination for older people. This sector is sometimes described as “values based” with this emphasis being one of the few common aspects of this large and diverse group of organisations. They are often seen to have the potential to add to integrated initiatives through their community links and independent mind set. Abersten et al. discover that despite such aspiration the reality of joint working with the public sector was often difficult, with a common perception that their contribution was not seen as being of equal merit to that of formal services. Their work was also seen by some as challenging their core value of independence, as undertaking statutory work may then compromise their ability to advocate for individuals and communities.
After this, Jenny Billings and Alison Davis describe work in Kent to develop a joint outcomes contract for integrated health and social care for older people. This is a crucial topic in the current policy context, and health and social care communities across the country are trying to find ways of working together which minimise barriers to collaboration and incentivise more joined-up approaches (with new contractual mechanisms a key focus). Indeed, an early review of emerging contractual models was one of the Journal of Integrated Care’s most downloaded papers in 2015. While this is often seen as a technical/legal/financial issue, the paper also focusses on broader relationships – beginning with the importance of shared values and agreeing key principles to guide the subsequent technicalities. While some people might see new contractual forms as setting out formal rules for how we work together, the process of developing such mechanisms appears to involve just as much of a focus on relationships, Trust, consensus building and agreeing what success would look like as other forms of partnership working.
In the penultimate paper, Mike Clark and colleagues provide a fascinating insight into the use of sporting memories to promote intergenerational working. This is a different approach to some of our more service-orientated papers, starting not with health and social care, but with key theories and approaches for developing and building upon shared values and social norms. Focussing on a series of practical examples, the paper explores what can happen when we begin with what younger and older people value, rather than necessarily what professional services value.
Finally, this double edition of the journal concludes with a viewpoint from Edge Hill’s Axel Kaehne, who will be joining the Journal of Integrated Care as a Co-editor in 2017. Reflecting on different approaches to evaluating integrated care, Axel adopts a more conceptual and theoretical analysis of the nature of complexity and what this means in practice for researchers in this difficult and contested field. Evaluation has been a common theme for the Journal of Integrated Care over many years, both for practitioners and policy makers seeking to understand the impact of their work and for researchers seeking to develop new insights from applying their skills to front-line innovations. Of course, coming together as a team to edit something as complex as a journal also involves significant discussion and debate about shared values – and we look forward to working together (practising what we preach in our editorials!) Regular readers of the journal will see more of Axel in 2017, and we offer him a warm welcome to the editorial team.
Gandhi predicted that “your values become your destiny” This edition of the Journal of Integrated Care suggests that values continue to shape how we are seeking to integrate in the future and our ability to generate benefits from these opportunities. On a final note, reflecting this importance the International Federation of Integrated Care is currently developing a set of values and principles to guide integration which will be launched in the spring of 2017.
Robin Miller, Jon Glasby and Sue White