Editorial

Citation

White, S., Miller, R. and Glasby, J. (2016), "Editorial", Journal of Integrated Care, Vol. 24 No. 3. https://doi.org/10.1108/JICA-05-2016-0019

Editorial

Article Type: Editorial From: Journal of Integrated Care, Volume 24, Issue 3.

Integrating integration: steering “innovative pilots” to become “business as usual”

In the UK, and indeed internationally, there is consensus across traditional political divides that integration must happen, but there are equally shrill voices lamenting the amount of work left to do. Knocking unhelpful structures down and forging new communicative practices across agencies and also across the life course is a complex business.

The imperative to integrate reproduces some familiar motifs in public service reform, one of the most noteworthy of which is the debate about the place of central control and role of local discretion and innovation. No longer are public services seen as the monopolistic prerogative of traditional bureaucracies, but are increasingly managed and delivered through networks of agencies: public, private and third sector. In this apparently centreless state, how do we integrate? Do we do this through self-organising networks – or do we need command and control?

Of course, whatever the blueprint, these matters are managed – won or lost – on the ground. They are brought into being through a combination of diverse skills and heterogeneous sources of authority: professional expertise, local knowledge, common sense, personal anecdote. The evidence for integration does not speak for itself. Indeed, without practical relevance the voice of evidence is voice is inherently weak. Research-style evidence is all too easily dismissed as “mere statistics” or “purely academic”, however valid and rigorous it might be in the scientific domain. Strong advocacy is required if evidence is to have any influence on decision making and if it is to assist in making integration business as usual. When integration has been successful it will have rendered itself redundant as a noun to describe public services – integration is only necessary because its anonym disintegration is at large. But, can people be made to integrate – can this be accomplished through political will. Do services need someone to steer, whilst they row?

The papers in this volume, in their various ways, revisit this question adding an international dimension. The first paper by Axel Kaehne reports the preliminary findings of an evaluation of an integration and service improvement programme in the children’s health care sector in Liverpool. The programme was led by the Local Clinical Commissioning Group but made use of a working group model with significant levels of autonomy. Thus it combined the steering with the rowing, seeking horizontal and vertical integration of children’s services. Children’s services raise particular challenges for integration. In complex care cases, parents, children and young people may find themselves dealing with a plethora of different organisations and professions and telling their stories multiple times. Managing the institutional risk associated with safeguarding creates further complexity. Co-ordination is key, but has proved elusive – teams around the child or family, do not necessarily function as teams. They may simply be an ad hoc assembly of interested folk, with different things on their organisational minds. The working group model was generally positively received by those who took part. Opportunities to meet face-to-face professionals from other organisations increased the real motivation to achieve collaborative working and gave insights into the realities of work and different priorities in various parts of the service.

However, commitment and enthusiasm waned over time and working group participants were operating mainly in strategic roles. Local authority services are as key in children’s services as they are in those for older people but they were under-represented. The paper concludes that future research needs “to reach out to those parts of the workforce that have no immediate interest in integration and are more likely to resist organisational change as it impacts local work practices or diverts resources away from embedded frontline practices”.

This is indeed imperative – organisational cultures and professional identities speak themselves. If these parts of the organisations are not engaged, attempts to steer the integration ship may be founded on the rocks as the frontline services row in a familiar but the wrong direction. The second paper by Natalie Davies, Wulf Livingston, Emyr Owen and Peter Huxley addresses the importance of legislative steer in health and social care integration in Wales. The Social Services and Well-being (Wales) Act 2014 has laudable aspirations to promote partnerships to improve public well-being. The paper reports on a mixed methods study exploring the views of senior managers on the Act and its implementation. Whilst the Act was welcomed and there was considerable proactive preparation before they have been identified – some “typical” of health and social care integration, for example, a lack of resources and organisational turbulence. There were many challenges to implementing integrated working. These are the recurrent leitmotifs of health and social care integration. Local collaboration partnerships work best when they go beyond engaging senior management to include into frontline staff, local communities and citizens themselves. Policy change, however uncontroversial its aspirations, is only one of many factors and processes which work to ensure the success or failure of attempts to integrate integration into everyday work. The paper concludes evolution not revolution is the way to go, but the questions remains, will the fittest survive?

The third paper by Lynn Wigens takes us round the globe to examine integrated care in Canterbury, New Zealand. This provides an important comparative perspective on attempts to reduce service fragmentation and promote integration. New Zealand has a no fault compensation insurance scheme for accidents and injuries and about 30 per cent of the population have private insurance to cover elective surgery. Chiming with the findings of the previous two papers, clinical leadership proved to be a crucial factor. Nursing leadership based on “stability, credibility and sound working relationships” combined with real participation by other clinicians, different agencies across sectors and significantly service users were key aspects of success. Education and appropriate user-centred information technologies were also central to success. If integration is to work, it has to move out of the board room and into the everyday encounters between professionals and between professionals and citizens.

Our fourth paper by Benjamin Ewert develops and problematises the notions of citizen and consumer which are so central to the integration “person-centred” policy rhetoric. The paper reminds us that when people engage with health and social care services they may occupy a range of identities from the relatively passive “patient” to active community self-help or advocacy positions. The challenge the authors argue is for health care initiatives and services to address users as a “whole”, incorporating shifting identities and needs. The tensions between services being responsive to the demands from communities for services to fit their life-worlds and the imperative to manage and treat acute disease in “patients” may explain some of the wickedness in the problem of integration. What are we integrating and for whom?

Sue White, Robin Miller and Jon Glasby