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Emerald Group Publishing Limited
Article Type: Editorial From: Journal of Integrated Care, Volume 23, Issue 6.
A “warts and all” approach to integrated care – understanding the potential benefits (and unintended consequences) of innovation
As we head into winter, all the signs suggest that health and social services will face an extremely tricky time. Faced with rising demand, serious financial challenges and unrelenting public, political and media expectations, front-line services are already struggling. In many places, morale feels shaky, and everyone feels under pressure. If it’s a bad winter and the usual “winter crisis” hits, then things could get very difficult indeed. At the very least, expect to see newspaper headlines around pressures on A&E, photos of ambulances queuing outside hospitals and mutual recriminations around delayed transfers of care.
In responding to all this, policy makes at national and local level are increasingly recognising that we will need to innovate in order to adapt to these challenges. Doing more of the same is unlikely to be sufficient, and something more fundamental may well be required. At the same time, there’s also a clear understanding that we can’t just innovate in silos: some form of joint working has to be part of the overall solution. Many of the problems we face are so significant and so complex that doing things separately is unlikely to be successful. With money so tight, we will have to find ways of eradicating duplication, filling gaps, responding to need in a more holistic way and genuinely being greater than the sum of our parts – not doing this simply won’t work and isn’t an option. However, responding to the pressures of the day job whilst also creating the time and space needed to develop new ways of working is incredibly challenging – and much will depend on the ingenuity of front-line staff, the passion and commitment of local leaders and the ability of everyone involved to pull together for the common good.
Against this background, the papers in this volume of the Journal all focus on innovations designed to promote more effective joint working and/or to transform future services. Sometimes these seem highly promising, and the challenge will be to share key lessons about what works and what helps/hinders with others as quickly and effectively possible, so that good practice can become everyday practice. However, some of the innovations being pursued might not be so positive and could easily have unintended consequences. Rather than making things better, they might actively make things worse – and we need to identify these potential negatives, stop the policies concerned and/or mitigate the risks as rapidly as we can. Of course, deciding whether a particular innovation is part of the solution or part of the problem is very much in the eye of the beholder, and different stakeholders might well have different views on the nature of the problems to be solved, the options available and the implications of new ways of working.
In light of this, the different contributions below all look at different types of innovation, and the authors form clear views as to what they see as potential benefits and what they see as innovations which might well be damaging. Almost by definition, this is likely to be controversial, and we fully expect this to be an edition which really gets readers going. For everybody who sees the reform of English children’s services as long overdue (as but one example), others will feel that current policy contains more risks than benefits. For everyone who feels that we shouldn’t throw the baby out with the bath water, there will be others who feel that current approaches are too complacent and that policy makers are right to pursue more radical options. We’ve therefore deciding to sub-title this editorial in terms of a “warts and all” approach to integration and to innovation more generally. Whatever your personal views, we hope that there may be much here to inspire you, to infuriate you, to make you want to pioneer similar responses locally and to make want to resist current policy as much as possible – all at the same time and all in one place!
Reflecting on current approaches to integration in a Scottish context, Ailsa Cook, John Harries and Guro Huby consider the skills that leaders of integration (often termed “boundary spanners”) need in order to handle the day to day complexity of their work. In particular, they focus on educational interventions to support new ways of working, concentrating on the case study of a Postgraduate Programme in Integrated Service Improvement: Health and Social Care. In the process they identify four key principles (grounding learning in experience; supporting the development of shared language; learning from each other, rather than just alongside each other; and skills development). For all that national policy urges greater collaboration, too much professional training still takes place in isolation, and some educational programmes feel just as siloed as some front-line services. If we continue to educate future workers in the same way as we always have done, then perhaps we shouldn’t be surprised if little changes in terms of their practice.
Of course, all developed countries are seeking (and arguably struggling to achieve) greater integration, and our next paper sees Olivier van Noort and Fredo Schotanus reflect on the Dutch experience. Focusing on a local pilot, key innovations include attempts to create a local population-based budget, with health care providers, insurers and the municipality working together across traditional boundaries. So many systems are currently trying to find ways of creating better aligned financial systems and incentives, so that the way money flows actively helps integration rather than acts as a barrier to more effective joint working. Here, the pilot had to overcome current regulations around competition, the complexities and contradictions of national policy, changes in key personnel locally – and many other barriers besides. Perhaps not surprisingly for regular readers of the Journal, the key lessons learned are more around culture, relationships and trust rather than around control mechanisms and formal negotiations – a common theme in many of our papers over time.
Next, Rebecca Jester and colleagues draw on lessons from the literature to design and present a practical framework for evaluating an innovative hospital at home service commissioned by Lambeth and Southwark Clinical Commissioning Groups. Too many new projects are set up at pace without sufficient time to consider the previous evidence or to build in scope for future evaluation. To guard against these dangers, this particular pilot sought to develop an evidence-based approach to the design of the service and to ensure an effective evaluation strategy. In addition to describing the approach taken to reviewing the literature, this paper also presents the evaluation framework itself so that others can learn direct from local innovation.
After this, Mary Baginsky and colleagues reflect on the issues of decentralisation and safeguarding in English schools. While successive governments have tended to see greater choice and decentralisation as key features of education policy, there’s also a risk that this could lead to greater fragmentation. Similarly, while some policies seek greater educational attainment (in terms of the number of GCSEs grade A-C, for example), others wonder whether this is fully compatible with attempts to promote greater inclusion of vulnerable children and children with special educational needs. Asking front-line services to work together is all very well, but perceived tensions in national and local policy can make this even harder than before if the policies and incentives are not fully aligned.
Following on from this, Ray Jones concludes this volume by critiquing what he sees as the marketisation of children’s social work and child protection. This powerful commentary and personal reflection reviews the history of children’s services, before considering the implications of more recent policy. While some would strongly agree and others might fundamentally disagree, Jones sees a growing trend towards privatisation which he feels will lead to greater fragmentation and a series of other negative consequences. Although strongly worded, this is an important and timely contribution – not least because debates about joint working frequently seem to skirt over the different mix of public, private and voluntary sector provision in different parts of the health and social care system. Indeed, this feels such a crucial debate that we would welcome future papers on similar topics and/or alternative viewpoints on the arguments which Ray puts forward.
Whatever winter has in store, it’s going to be a challenging time, and (as always) we hope that the papers published in this edition of the Journal can contribute to future solutions. Almost by definition, some innovations will work, and others won’t – and debates around what we’re trying to achieve in the first place, what’s been effective in practice and what we should do next are bound to be contested. Please read, reflect and respond!
Jon Glasby, Robin Miller and Sue White