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This article reports on the experiences and evaluations of piloting health and social care discharge co‐ordinators in acute and community hospital settings. Benefits were felt with regard to length of stay, bed day use, and patient and staff experience, and were particularly notable where a discharge co‐ordinator employed by the community trust was put into the acute hospital setting. The pilots have supported a redesign of hospital discharge processes across Torbay Care Trust and South Devon Healthcare NHS Foundation Trust, and provided the foundation for improved partnership working and integrated service provision.

In the UK, there are around 1.5 million carers of people with mental health problems providing substantial amounts of free care. Despite having a legal right to a ‘carer's assessment’, only a minority of mental health carers have had such an assessment. To try and understand why the uptake is so low, we undertook a small (n = 8) qualitative study exploring what mental health staff acting as ‘care co‐ordinators’ thought the barriers to, and facilitators of, carers' assessments might be, and how subsequent practice might be improved.We found that there was some confusion over the definition of ‘carer’ and over who should take responsibility for carer assessments. The main barriers to carers' assessments were the documentation used, the attitudes of staff (especially managers) and the fact that the needs of mental health carers often differed from those caring for people with a physical disability. Practice could be improved through: clarifying the definition of ‘carer’; education and training; redesigning the documentation; dovetailing service user and carer needs assessments; and through offering a wider choice of evidence‐based services as assessment outcomes. Improvements are unlikely to be successful, however, without the active support, expertise and engagement of carers.

De‐institutionalisation and the closure of long‐stay hospitals brought about an increased focus on the development of alternative systems for the safe and effective treatment of people with mental health problems. One result of this focus was the introduction of the care programme approach or CPA (DoH, 1989; 1990a; 1990b). The main elements of the CPA are systematic arrangements for assessing the health and social needs of people accepted into mental health services, formulation of a care plan which identifies all health and social care needs, and appointment of a care co‐ordinator to keep in close touch with the patient and to monitor care, regular review, and, if necessary, agreed changes to the care plan.Though the CPA was originally seen as a mechanism to ensure proper aftercare for those discharged from hospitals, the Government later made it clear that it should be seen as a framework for the delivery of mental health care (DoH, 1998). All health authorities are now required to implement it for people with mental health needs referred to specialist psychiatric services.

This integrated care study seeks to highlight how voluntary sector “wellbeing co-ordinators” co-located in a horizontally and vertically integrated, multidisciplinary community hub within one locality of an Integrated Care Organisation contribute to complex, person-centred, co-ordinated care.

This is a naturalistic, mixed method and mixed data study. It is complementing a before-and-after study with a sub-group analysis of people receiving input from the wider hub (including Wellbeing Co-ordination and Enhanced Intermediate Care), qualitative case studies, interviews, and observations co-produced with embedded researchers-in-residence.

The cross-case analysis uses trajectories and outcome patterns across six client groups to illustrate the bio-psycho-social complexity of each group across the life course, corresponding with the range of inputs offered by the hub.

To consider the effectiveness and mechanisms of complex system-wide interventions operating at horizontal and vertical interfaces and researching this applying co-produced, embedded, naturalistic and mixed methods approaches.

How a bio-psycho-social approach by a wellbeing co-ordinator can contribute to improved person reported outcomes from a range of preventive, rehabilitation, palliative care and bereavement services in the community.

To combine knowledge about individuals held in the community to align the respective inputs, and expectations about outcomes while considering networked pathways based on functional status, above diagnostic pathways, and along a life-continuum.

The hub as a whole seems to (1) Enhance engagement through relationship, trust and activation, (2) Exchanging knowledge to co-create a shared bio-psycho-social understanding of each individual’s situation and goals, (3) Personalising care planning by utilising the range of available resources to ensure needs are met, and (4) Enhancing co-ordination and ongoing care through multi-disciplinary working between practitioners, across teams and sectors.

Increasingly mental health services are attempting to become recovery focused which demands changing the nature of day-to-day interactions and the quality of the experience in services. Care planning is the daily work of mental health services and within this context, care planning that enhances both the experience and the outcomes of a person's recovery is a key element for effective services. However, care plans, the care planning process and the Care Programme Approach (CPA) continue to pose a challenge for services. The purpose of this paper is to discuss these issues.

Conceptual paper.

Within recovery focused services a care plan becomes the driving force, or action plan, behind a person's recovery journey and is focused on their individual needs, strengths, aspirations and personal goals. If involving people directly in the development of their care plan is critical to creating better outcomes then supporting self-management, shared decision making and coproduction all underpin the care planning process. Based on the evidence of people's experience of care plans and the care planning process it is time to seriously debate our current conceptualisation and approach to care planning and the future of the CPA.

The paper describes aspects of the current situation with regard to the effectiveness of care planning in supporting a person's recovery. The paper raises some important questions.

The purpose of this paper is to describe and analyse ways of organizing integrated care for older persons in Sweden during the past decade.

The data consist of 62 cases of development work, described in official reports. A meta-analysis of cases was performed, including content analysis of each case. A theoretical framework comprising different forms of integration (co-ordination, contracting, co-operation and collaboration) was applied.

Co-operation was common and collaboration, including multiprofessional teamwork, was rare in the cases. Contracting can be questioned as being a form of integration, and the introduction of consumer choice models appeared problematic in inter-organization integration. Goals stated in the cases concerned steering and designing care, rather than outcome specifications for older persons. Explicit goals to improve integration in itself could imply that the organizations adapt to strong normative expectations in society. Trends over the decade comprised development of local health care systems, introduction of consumer choice models and contracting out.

Most cases were projects, but others comprised evaluations of regular organization of integrated care. These evaluations were often written normatively, but constituted the conditions for practice and were important study contributions.

Guiding clinical practice to be aware of importance of setting follow-up goals.

Awareness of the risk that special funds may impede sustainable strategies development.

A theoretical framework of forms of integration was applied to several different strategies, which had been carried out mostly in practice. The study contributes to understanding of how different strategies have been developed and applied to organize integrated care, and highlights some relationships between integration theory and practice.

The authors describe the rationale for key worker services for disabled children, factors to consider in developing such services, the role of key workers, how a key worker service is operating in one authority and the impact it has had for families who received it.

This case study focuses on a young man with severe intellectual disability and autism who engaged in high‐frequency self‐injurious behaviour. Permission to publish this article was given by the individual's mother. The case study offers a review of the input from the local Learning Disabilities Team, particularly from the behaviour support service. The input concentrated on co‐ordination of care, as part of the care programme approach. The care programme approach (CPA) was introduced by the Department of Health in 1990 to provide a framework for effective mental health care for people with severe mental health problems.

This article is the second which the Journal of Integrated Care has published about the Hartlepool connected care pilot. It takes up the narrative from the launch of the community audit report in February 2006 to the project's successful bid to become one of the 26 DoH social enterprise pilots some 12 months later. It seeks to understand the barriers encountered as the pilot sought to implement a service model based on an audit of local needs and ambitions. It identifies the need for support outside the local policy systems if holistic, community‐based initiatives are to be initiated and implemented. In addition, it considers some of the implementation dilemmas that the pilot posed for local agencies and that it had itself to face and resolve during this second phase in its development.

The aim of this action research was to explore, from a workforce and a patient/carer perspective, the skills and the capacity required to deliver integrated care and to inform future workforce development and planning in a new integrated care system in England.

Semi-structured interviews and focus groups with primary, community, acute care, social care and voluntary care, frontline and managerial staff and with patients and carers receiving these services were undertaken. Data were explored using framework analysis.

Analysis revealed three overarching themes: achieving teamwork and integration, managing demands on capacity and capability and delivering holistic and user-centred care. An organisational development (OD) process was developed as part of the action research process to facilitate the large-scale workforce changes taking place.

This study did not consider workforce development and planning challenges for nursing and care staff in residential, nursing care homes or domiciliary services. This part of the workforce is integral to the care pathways for many patients, and in line with the current emerging national focus on this sector, these groups require further examination. Further, data explore service users' and carers' perspectives on workforce skills. It proved challenging to recruit patient and carer respondents for the research due to the nature of their illnesses.

Many of the required skills already existed within the workforce. The OD process facilitated collaborative learning to enhance skills; however, workforce planning across a whole system has challenges in relation to data gathering and management. Ensuring a focus on workforce development and planning is an important part of integrated care development.

This study has implications for social and voluntary sector organisations in respect of inter-agency working practices, as well as the identification of workforce development needs and potential for informing subsequent cross-sector workforce planning arrangements and communication.

This paper helps to identify the issues and benefits of implementing person-centred, integrated teamworking and the implications for workforce planning and OD approaches.