Integrated Working: 'An Overview'

Watch a video introduction on integrated working.

• Video transcript Open

  Narrated film including reflections from:

  • Hugh Constant – Social Care Institute for Excellence
  • Prof. John Carpenter – School for Policy Studies, University of Bristol
  • Elaine Cass – Social Care Institute for Excellence
  • Gill Pratt – Registered Manager, Timberdine Nursing & Rehabilitation Unit
  • Stuart Townsend – Service User
  • Dr. Lisa Bostock – Social Care Institute for Excellence
  • Dr. Joe Hall – General Practitioner, Bromley-by-Bow Centre
  • Jamie – Service User
  • Annabelle – Service User
  • Damon Palmer – DH Lead for Health & Social Care Integration, UK Department of Health
  • Prof. Jon Glasby – Director, Health Services Management Centre, Birmingham University
  • Margaret Flynn – Independent Chair, Stephen Hoskin Serious Case Review
  • Dr. Tom Van Den Bossche – GP, West Wandsworth Community Ward
  • Michael Clark – Patient, West Wandsworth Community Ward
  • Shirley Ellis – Social Worker, West Wandsworth Community Wards

  Jamie – service user: All of the different places are battling for the same cause.
  But they do it separately so they're not as effective whereas if they all teamed up together they'd make a lot more impact and be able to help people a lot better.

  Narrator: Individuals often need to use a range of services including health care, social care, housing, and the criminal justice system.
  Historically, these services had limited experience of working together.

  Prof. Jon Glasby: Well our welfare state is based on a very 1940s assumption that you can distinguish between people who are sick who are the responsibility of the health service and people who are somehow merely frail or disabled who we describe as having social care needs that are the responsibility of local government.
  And people are means tested and paid towards the cost of their care.
  I'm not sure if that distinction ever made sense but it feels increasingly unfit for purpose in the early 21st Century given current demography.

  Narrator: Increasingly organisations and practitioners are realising the benefits of looking beyond their own service and practice to meet the needs and wishes of people who use their services.

  Dr. Joe Hall: We obviously deal with medical conditions day in day out however we can only take those patients so far dealing with their medical problems. 
  They often have social issues that we need to deal with housing issues that need to be dealt with and other issues that are blocking them from actually moving forward in their health.

  Narrator: When services are not joined up what are the consequences to service users and carers?

  Hugh Constant: Time and time again the people that use social care services and health services tell us how fed up they are with having to tell their story to a social worker one day to a community nurse the next day.

  Narrator: Too often, service users and carers need to find information themselves, and to push for the support they need.

  Elaine Cass: It's recognised that when you work in a fragmented way that people fall through the gaps.
  They receive a poor service or they don't get what they need or they have to continually wade their way through bureaucratic systems that are not joined up or interlocked.

  Narrator: For some individuals a lack of joined-up services can have serious consequences as Annabelle discovered when she made the transition from children's to adult's services.

  Annabelle – service user: A few months after my official discharge I was admitted into psychiatric intensive care for attempting suicide. 
  You are stuck in an institution trying to find which way's up.
  No one ever signposted me to an organisation that could have helped.
  It was me sitting on the internet going, I need something more than this!

  Narrator: In July 2006 the body of Stephen Hoskin was discovered at the bottom of a railway viaduct near his home in Cornwall. He had been murdered.
  Stephen had a learning disability.
  Desperate for friendship he had accepted a group of people into his home.
  Several of this group were later convicted for the brutal killing of Stephen.
  The leader of the group was Darren Stewart.
  He was already known to agencies because of his criminal activities and being a frequent user of services himself.
  Investigations revealed that Stephen had made several calls and visits to a number of agencies all of which should have alerted people to the danger of his situation and his vulnerability.

  Margaret Flynn: It seemed to me that every agency had a small piece of information or even quite a large piece of information but they looked at that information as though it was disconnected from anything else. 
  One of the principle findings of the serious case review was that every agency had a piece of a jigsaw but at no stage did they seek to discuss the information that they held or the concerns that they had about Stephen's circumstances.
  That's not to say that these agencies acted in a way that they knew of the danger that Stephen was in, they did not see it coming.
  So it had a very major impact on all services.

  Narrator: The agencies concerned have since made major changes to prevent this type of tragedy from happening again.
  Integration is not just about joint working between agencies.
  It also requires integration within each agency across all parts and between each level of the organisation.

  Annabelle – service user: Every services seems to have an us and them
  There seems to be a divide between psychiatrists and nurses, psychiatrists and therapists, therapists and nurses.
  And then there's the divide between NHS and charities.
  And then there's the divide between the patient and professionals
  And when you've got so many divides information gets lost, information doesn't get shared and the best advice isn't given.

  Narrator: But effective integrated working does happen - both within and between agencies producing positive outcomes for service users and carers.
  Professor John Carpenter was the co-author of a study which compared integrated and non-integrated working of health and social care.

  Prof. John Carpenter: We did find differences, that the service users in integrated teams were more satisfied with the quality of their care, they were more likely to say that they had been involved and they were more likely to say things like that they'd been fully informed about their medication and needs in those kinds of respects too.

  Narrator: There are many different models of integrated care, including the approach taken by the Timberdine Nursing and Rehabilitation Unit in Worcester.

  Gill Pratt: Here we are what I would consider truly integrated, we've got everybody that we need within our service area, within easy reach.
  Within our building we actually have social workers we have therapists, obviously our nurses are based here and our care staff.
  But we have consultants coming in on a planned rota, we have GPs coming in to see us every day on a planned rota, we can easily access mental health advice.
  We have ophthalmology coming in to see us, we have stroke services coming in to see us.

  Narrator: Stuart Townsend had experienced a lack of joined up care in the past, but what are his experiences at Timberdine?

  Stuart Townsend: Oh, it's just totally flipside and everything I have to say is positive
  I can't think of one negative.
  You know, it was, even from going home it didn't end once I left here.
  It was chairs that were give to me and aids that were given
  Anything that they could do here for me here they've done for me
  
  Gill Pratt: I think it enables us to do things in a more timely fashion for people.
  It means were not waiting for things for service users.
  If, for example, they need a financial assessment done to enable them to get a care package we can get that done quickly and easily
  If they need a hospital appointment our consultant can quite often make that happen more easily or get the referral through the right person quite quickly.
  Matron's got a lot of links with different people so she can makes things happen so it means people have all the facets of their care taken care of more quickly and easily and get them to where they need to be.

  Narrator: In Wandsworth, South London, integrated teams aim to reduce the number of hospital readmissions of people with multiple co-morbidities and significant health needs.
  These teams known as 'community wards' care for people in their homes using telehealth technology and face-to-face care.

  Staff member: A neighbour just phoned to inform she's not feeling very well and should you like to speak to her at all?

  Narrator: Each team comprises a GP, social worker, advanced nurse practitioner, pharmacist and community matron
  The medical staff are able to call on the community ward social worker to carry out assessments, organise care packages and ensure people get suitable support.

  Dr. Tom Van Den Bossche: At home you actually do get to see them, give them more time.
  You can see the environment they live in so some people can look after themselves, they have family.
  Other people are completely alone so when you come into a home you can actually assess a lot more than just a medical condition.

  Narrator: Shirley Ellis is a social worker on one of the integrated teams

  Michael Clark: I must have known.

  Shirley Ellis: Good morning Mr Clark. How are you?
  How have you actually found the benefits of actually being on the community ward?

  Michael Clark: Completely and utterly brilliant because it's stopped me being in hospital.
  Prior to that I was going 6 weeks, maybe 8 weeks and then I was in hospital for 10 days.

  Narrator: Given the existence of different models for integrated working, the Social Care Institute for Excellence conducted a systematic review of factors that promote and hinder joint working.
  The factors can be grouped under three broad issues:
  organisational
  cultural and professional
  and contextual.

  Dr. Lisa Bostock: Under the organisational theme it was things like are we clear about our aims and objectives?
  Are we clear about what we're trying to achieve here?
  And when people got that right then services flourished.
  But when people weren't clear and people who were maybe outside of that particular joint working initiative ie. people who might be referring into that service weren't clear about the aims of that service then that's when things began to fall down. 

  Ailsa Cameron: For example, when different professionals are working together they've got to agree and accept assessments other groups provide
  So, for example, when working with older people, an assessment might be carried out by a social worker but the community nurses have to be confident in that assessment and trust that assessment in order to action it.

  Dr. Lisa Bostck: Contextual issues refer to the background in which integration takes place.
  So it can relate to the political climate, discussions that are going on.
  So at the moment discussions about the numbers of older people affect how services are responding may raise new issues for organisations that they have to deal with
  It affects how the senior managers are planning and negotiating and commissioning services and what happens at that strategic level filters down to the operational level.
  So if there are anxieties about cost shunting at the strategic level those get played out at the organisational level.

  Narrator: Just as open and constructive discussions between agencies are essential to plan effective joint working, so is genuine dialogue with service users and carers.

  Jamie – service user: They might all sit down and say 'oh we need to change this, we need to change this' but if they get someone from the perspective of the patient then they can see what they think needs to be improved rather than what the professional think need to be improved.

  Narrator: Successful integrated working depends on service users, carers and families being empowered to make decisions about their individual care.
  It also depends on their close involvement in the planning of such care.

  Damon Palmer: We will also have to plan more around how we will treat and care and respond to individuals with complex care packages and they will require multi-disciplinary teams and mulit-disciplinary responses and therefore I think integrated working will become the norm as we go forward rather than the exception.

  Prof. Jon Glasby: As budgets get tight and as structures change joint working is even more important now than it ever was. 
  And if ever there was a time for frontline professions and practitioners to stand up and to be counted to make relationships work at a local level, to see the world in broader ways and to develop new ways of working alongside other agencies and other professionals, that time's now.

What is the video about?

People often need to use a range of services including health care, social care, housing, and the criminal justice system. Increasingly, organisations and people who are responsible for providing care and support, are realising the benefits of looking beyond their own service and practice. They’re integrating to meet the needs and wishes of people who use their services.

People arriving at a health centre often have social issues that we need to deal with, housing issues that need to be dealt with and other issues that are blocking them from actually moving forward in their health. The film looks at the death of Stephen Hoskin in 2006. One of the principle findings of the serious case review was that every agency had a piece of a jigsaw but at no stage did they seek to discuss the information that they held or the concerns that they had about Stephen's circumstances. The agencies concerned have since made major changes to prevent this type of tragedy from happening again.

Messages for practice

• It's recognised that when you work in a fragmented way that people fall through the gaps.
• When different professionals are working together it’s important that they agree and accept assessments other groups provide.
• Integration affects how the senior managers are planning and negotiating and commissioning services and what happens at that strategic level filters down to the operational level.

Who will find this useful?

Anyone who works in the caring professions, from nurses to care home managers, from local authority commissioners to occupational therapists.