At a glance 57: Integration: Implications for people who use services, practitioners, organisations and researchers

Published: March 2012

Key messages

Introduction

All governments in the last 40 years have promoted integrated working in health and social care. Rising demand for services, coupled with the need to reduce public expenditure provide compelling arguments for greater collaboration. Additionally, integration offers further means of supporting people with complex needs to live independently in the community. However, the question remains whether or not reforms have met the objectives set by policy-makers.

This At a glance briefing discusses the implications of integration for people who use services, practitioners, organisations and researchers. It summarises implications identified in SCIE research briefing 41 Factors that promote and hinder joint and integrated working between health and social care services (Cameron et al, 2012). The research briefing updates a previous systematic review on this topic (Cameron and Lart 2003), and focuses on jointly-organised services for older people and people with mental health problems.

The original review concluded that while the literature had a lot to say about the process of joint working, very little attention had been paid to exploring the effectiveness of this approach either for users and carers of services or the organisations providing services. SCIE's research briefing updates the original review and considers the impact of policy and practice reforms over the past decade. While the research evidence base is lagging behind current policy and practice, it provides new joint working initiatives such as clinical commissioning groups and health and wellbeing boards with a solid base from which to consider the factors that promote and hinder joint work.

Outcomes defined by people who use services may differ from policy and practice imperatives, and are a crucial aspect of understanding the effectiveness of integrated services.

Models of joint working

The research briefing looks at UK-based evaluations of jointly-organised services to older people and people with mental health problems. Within this, research is overwhelmingly focused on frontline services and service delivery. Studies identify the following models of joint working:

• multi-agency teams
• placements of individual staff across agency boundaries
• co-locations of staff that were not formal teams
• single assessment processes (SAP)
• the provision of intermediate care
• structurally integrated services
• use of pooled budgets.

Factors that promote and hinder joint working

Three broad themes are used to organise the factors that support or hinder joint working: organisational issues; cultural and professional issues and contextual issues. These themes reflect the original review, although new areas of interest within the themes have emerged such as the importance of 'flexible roles'. Interestingly, there is significant overlap between factors; with many of the organisation factors that promote joint working, serving to hinder collaboration when insufficient attention is paid to their importance.

Implications for people who use services and carers

Defining outcomes that matter to people who use services and carers is essential. Outcomes defined by service users may differ from policy and practice imperatives, and are a crucial aspect of understanding the effectiveness of integrated services from the perspectives of people who use services themselves.

Although most service users and carers report high levels of satisfaction, more can be done to involve them in care planning and enable them to influence future care options. Integrated services work best when they promote user involvement, choice and control.

Integrated services work best when they promote user involvement, choice and control.

People who use services and carers value services that are appropriate to their needs – they are less concerned with how these are organised. Service users value timely assessment and services; partnership and the development of trusting relationships with named key workers and improved communication and coordination between the agencies. Carers value assessment in their own right and welcome additional support, particularly when they are service users themselves.

Involving staff, particularly health professionals in the development of initial plans for joint ventures is crucial to future working relationships.

Implications for practitioners

Working together effectively appears to require practitioners to reconcile their professional values and roles with the aims and objectives of the joint initiative. One way to achieve this is to ensure that the outcomes for people who use services and carers are made explicit from the start.

Sharing information in a timely and appropriate fashion is also crucial to joint working. Attention has focused on establishing the means to share information (shared databases and IT systems). However, some professional and cultural barriers to information-sharing remain. Professionals need to feel confident in the processes for sharing information and understand how this benefits people who use services.

Implications for organisations

New partnerships and integrated services need to be developed to enable the different professions and agencies involved to understand one another's aims and objectives, and identify the desired outcomes before they start. Involving staff, particularly health professionals in the development of initial plans for joint ventures is crucial to future working relationships. This is one way to overcome initial misconceptions about new services. Regular meetings provide an opportunity to develop policies and procedures as well as offering a setting to resolve problems and review practice.

Any joint working venture should have transparent and appropriate management arrangements. They should incorporate both professional and organisational managerial support. This would help staff feel more secure and confident in their new roles and new working contexts.

Implications for research

There is a need for researchers to sharpen the approaches brought to studies of joint working. While some large-scale, complex studies of joint working exist, evidence is largely based on small-scale 'boutique evaluations' of local initiatives that make it difficult to draw firm conclusions about the effectiveness of joint working. The central issue for research is to develop ways of identifying and evaluating the outcomes of joint working for users and carers.

Studies should describe more clearly the organisational models being used, as a basis for assessing and comparing costs and benefits. Words like 'team' cover a multitude of forms, and it was not always possible to discern from the published papers how different research sites operated in terms of some of the key issues like communication, information sharing and management arrangements. No evaluation included an analysis of cost-effectiveness.

Summary

There are some tentative signs that progress has been made since the original review of the factors that promote and hinder joint working. It is now possible to demonstrate some positive outcomes for people who use services, carers and the organisations delivering services. However, the evidence base is patchy and more research is required to sharpen and broaden our understanding of these outcomes. Without clear data on effectiveness, some professionals remain sceptical about the importance of joint and integrated working to users of adult health and social care, and the need to involve them fully in care planning and influencing future care options.

References

1. Cameron, A. and Lart, R. (2003) Factors promoting and obstacles hindering joint working: a systematic review of the research evidence. Journal of Integrated Care, 2003. 11(2): p. 9–17.
2. Cameron, A., Lart, R., Bostock, L. and Coomber, C. (2012) Factors that promote and hinder joint and integrated working between health and social care services (Research briefing 41). London: SCIE.