Editorial

Citation

Thistlethwaite, P. (2012), "Editorial", Journal of Integrated Care, Vol. 20 No. 5. https://doi.org/10.1108/jica.2012.55320eaa.001

Editorial

Article Type: Editorial From: Journal of Integrated Care, Volume 20, Issue 5

This editorial focuses on integrated care research, and has been stimulated by our lead article in this issue by Geoffrey Meads and colleagues. They have provided us with an innovative analysis of what has been happening in the very recent past in the allocation of grants for health services research which is specifically and broadly relevant to integrated care. Thinking ahead, these are the studies which will give us the evidence base of the future.

The context for Meads and colleagues is the current heavy policy interest in furthering integrated care, both within the NHS and wider. But this context is not new, although it is probably stronger now than at any earlier point in the history of this journal. It is a positive reminder of another innovative study of more than ten years ago, funded rather quixotically by the NHS Research and Development office for the South West Region. Given the interest in “joint working” apparent in the late 1990s, the aim was to undertake a systematic review of the evidence base for it. It was a commission which was definitely before its time. The work was undertaken by a team at the School for Policy Studies at Bristol University in 2000-2002. In addition to the report for the commissioner, a summary was published in this journal in 2003: “Factors promoting and obstacles hindering joint working: a systematic review of the research evidence” by Ailsa Cameron and Rachel Lart, two members of the team. The impact factor of this article remains high.

To this day, I have never understood why this work was not commissioned on a national basis. The result was that the messages in the Bristol work were never at the core of the national policy drive. Many leading academics and policy advisers seemed to miss it and therefore its significance. However, in the background, its relevance to day-to-day organisational life for care providers has been sustained, and its lessons have obvious and immediate practical application. The review provides a checklist for action to integrate. Although I have no certainty about this, it may be that its messages were of more interest to social services than to health services. If so, the reason may be the many distractions affecting health service organisation which had the potential to marginalise joint working.

The relevance of this context today is that Cameron and Lart have recently updated their review – for the Social Care Institute for Excellence (SCIE) (www.scie.org.uk/publications/briefings/briefing41/). It is a look back at similar relevant research published in the decade that followed, through the lens of the themes they had originally identified. It felt familiar as I read it, but it reminded me of the phases of fashion in policy focus in that decade. The early studies found in the review revealed a strong focus on joint working in mental health services, where there had been less resistance from local authorities to enter into partnerships with the NHS than in other, more mainstream, services. We learned a lot from these studies, but mental health is more barren territory now with Foundation Trust status and funding uncertainties blighting developments. The second phase concerned “intermediate care” with the SCIE review finding a number of studies in the middle part of the decade analysing joint working at various levels in these new services which, we remember, were themselves driven by needs in the NHS to tackle the twin problems of unnecessary hospital admissions and delayed discharges. This followed a celebrated Audit Commission study of the lack of effective rehabilitation services in 2000 (www.audit-commission.gov.uk/nationalstudies/health/socialcare/pages/thewaytogohome.aspx). The fashion for intermediate care, whilst by no means over, has now been subsumed into broader concerns about increasing demands for hospital care by older people and their families which need to be met by new forms of integrated services involving primary and community health care, acute care and social care. The studies cited by Meads and colleagues are going to be rooted in this phase.

The SCIE review concludes that “the evidence base is patchy”, and there does seem to have been a shortage of comprehensive and heavyweight studies meeting the review inclusion criteria. The review conveys the patchwork nature of evidence available, which can be set against the work done by the Kings Fund and Nuffield Trust in the last three or so years to assemble international evidence on the benefits of integrated care.

Meads and colleagues see positive signs, whilst recognising an obvious deficit for integrated care compared to the clinical world where randomised controlled trials and their meta-analyses predominate: “this deficit is readily understood, given the multi-variable and essentially contingent nature of Integrated Care, but it is still a drawback for those seeking to establish as normative the models of Integrated Care”. They maintain a positive stance because of the prestige of the schools currently obtaining grants, the size of those grants, and the emergence of excellence in this field in newer universities. Concluding that “Integrated Care has become an important and standard dimension of health services research in England”, they nevertheless highlight that this may come to be “excessively influenced by narrower clinical, and more vertically related, agendas”, and point out that Social Scientists are not prominent enough in leading the recently funded studies. This is perhaps an illustration of the risk of NHS dominance observed earlier.

On one topic, Cameron and Lart and their SCIE colleagues are of one mind with Meads and his colleagues: a focus on patient and public involvement in research, and an associated, more prominent, concentration on outcomes for service users and carers, is required. I expect that Ailsa Cameron and Rachel Lart will write further on this for Journal of Integrated Care in the near future.

An old chestnut will surely come to mind from all this: who will apply the evidence when it is finally conducted, vetted and published? Currently, the link between research and policy seems strong, and this may in itself lead to improved experiences for the public. But there seem to be continuing barriers to evidence-informed organisational and practice change. It is here that the real interests of service users and carers lie.

Peter Thistlethwaite