Enhancing Outcomes: Integrated Care for Mental Health, Disabilities, and Justice Users, Summaries of Communication

Download Enhancing Outcomes: Integrated Care for Mental Health, Disabilities, and Justice Users and more Summaries Communication in PDF only on Docsity!

b r i n g i n g t h e n h s a n d l o c a l g o v e r n m e n t t o g e t h e r

A practical guide to integrated working

What is the Integrated Care Network?

The Integrated Care Network (icn) provides information and support to frontline nhs and local government organisations seeking to improve the quality of provision to service users, patients and carers by integrating the planning and delivery of services. Key to the role of the icn is facilitating communication between frontline organisations and government, so that policy and practice inform each other effectively. The icn is part of the Care Services Improvement Partnership (csip).

Care Services Improvement Partnership

csip was launched on 1 April 2005 after a formal public consultation. Our main goal is to support positive changes in services and the well-being of:

• people with mental health problems
• people with learning disabilities
• older people with health and social care needs
• children and families
• people with health and social care needs in the criminal justice system. icn offers advice on partnerships and integration that cut across all services in health and social care. It works closely with other networks and programmes across csip to ensure synergy in improvements.

History of the guide

This is an updated version of Integrated Working: A Guide (2004). The contents of both versions have been devised and written by Peter Thistlethwaite, who is a specialist R&D consultant in integrated care. Like its predecessor, the new version has been designed and edited at Dartington Social Research Unit by Kevin Mount.

We are grateful to Julia Thompson, Jeremy Porteus, Chris Mahony, Ed Harding and Robin Lorimer of icn for their support and ingenuity in helping us develop the update.

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

Foreword

There comes a point when the value of an idea is so well- established that practical advice on implementation is more important than another slice of theory. That is the thinking behind this document which seeks to help organisations in the NHS and local government deliver integrated services – for the benefit of local users of services.

For the Department of Health, cohesion and co-ordination in adult social care are among the key priorities for 2008. That, of course, reflects the continuing Ministerial emphasis on integration – as outlined in Putting People First , the concordat between central and local government published in December which set out a shared vision and commitment to the transformation of adult social care. It said: “Ultimately, every locality should seek to have a single community-based support system focussed on the health and well-being of the local population. Binding together local government, primary care, community-based health provision, public health, social care and the wider issues of housing, employment, benefits advice and education/training.”

This guide – a timely update to the 2004 Integrated Care Network (ICN) publication – is a response to these challenges. The benefits of integrated care systems in improving outcomes for services users are clear – the question is how best to achieve them. This guide brings together the latest changes in policy and best practice, and aims to support organisations in the NHS and local government along the road to integration.

pen pictures

• How to use the guide
• What integration should mean for your locality or service
• Self assessment: some integration benchmarks
• Part One: Knowing more about integration
• 1 Agreeing what ‘integration’ means
• 2 The journey to integration
• 3 How evidence of what works can help
• 4 Understanding the potential benefits
• Part One in summary
• Part Two: Making it happen
• 5 Community-wide governance
• 6 Commissioning together
• 7 Providing integrated services
• 8 Putting integrated care into practice
• The guide in summary
• 1 Establishing a user focus
• 2 Barnsley
• 3 Herefordshire
• 4 Peterborough
• 5 Knowsley
• 6 South Tyneside
• 7 Commissioning for prevention and early intervention
• 8 Torbay Care Trust
• 9 Telford and Wrekin Children’s Services
• 10 Sandwell Mental Health
• 11 Sedgefield
• 12 Castlefields Surgery, Runcorn

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

If you have the power to change policy or local practice, then this guide has been written for people like you. Integration needs leaders at all levels who can rise above their usual roles and responsibilities, and, with support from their employers, work with a range of professionals and organisations to improve outcomes and experiences for users. The guide aims to provide you with the necessary practical back-up. Try to read the guide from start to finish, although you can pick and choose from the sections. The broad aim is to help you to gather a picture of where you stand locally with the integration agenda, so that you can map out and sustain your own development process. So this is purposely more of a traveller’s guide than a textbook; the intention is to provide a carefully sequenced and organised combination of ideas and practical guidance, supplemented by: focal points from national policy messages from research pen pictures of early adopters of integration

You can get an early feel of what a more integrated approach might mean by assessing your locality or service against the integration benchmarks given on pages 10 and 11. This may also help you to decide where the guide can help you most. There is no single route to follow. The guide provides stimulus and ideas to support well thought-out local choices about integration.There is no prescription: a variety of approaches to suit local conditions and histories will continue to be appropriate. In some services frontline practice may actually be ahead of official local policy and strategy: part of the message is to encourage all leaders to promote communication across and between organisations, to make plans in response to local needs and, in the best sense of the word, to improvise.

CSIP organises four networks in addition to the Integrated Care Network. One is devoted to Leadership and Teamwork Development and provides an avenue to a wide range of opportunities for learning and practice exchange and access to online resources.

How to use the guide

The different information strands use these three colours throughout.

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

The purpose of integration is to improve service user experience and outcomes. This is done by minimising organisational barriers between different services, and between services and commissioners. Promoting better public services through integration has been the clear intent of recent government legislation and policy and is now regarded as the norm rather than something exceptional or unusual. Key recent documents such as Every Child Matters and the Children’s Act 2004 which followed it, the DH White Paper Our Health, Our Care, Our Say, (2006) and the Local Government White Paper Strong & Prosperous Communities (2006) signal the clear intent for higher standards and more integrated provision for service users. This has been reinforced by Putting People First (2008), a ministerial concordat on adult social care services, which places integration centre stage in the policy drive towards greater personalisation of services. But how integrated is care planning and provision in your locality and service?? Is it in place at every level from strategic vision to day-to-day practice? How much progress has been made to ensure that users get the benefits of integration, for example:

• the easiest access to advice and help
• the simplest processes for assessment and decision-making
• the swiftest delivery of whatever help is needed
• the least risk of errors and unnecessary stages in the process (and no passing the buck)
• the maximum opportunity for controlling events themselves? All of these are features of an effective system of care, and all are difficult to optimise without a local commitment to partnership and integration from politicians, directors, policy makers, managers and practitioners. They also require the engagement of users and carers. The key benefits have been demonstrated in research and in case study evaluations of the provision of care, some of which are highlighted in this guide.

What integration should mean for your locality or service

What integration should mean for your locality or service

The Integrated Care Network was brought into being to support the realisation of these aspirations. The five target areas for development it established form core elements of the rest of this guide: access, reshaping services, community engagement, reshaping resource flows and workforce development.

These messages have featured strongly in policy and research papers for years, but many readers will acknowledge that local progress has been uneven, and that the obvious barriers may seem insuperable despite the best efforts of professionals and planners. Whilst certain specially-funded schemes may have broken the mould (e.g. the Partnerships for Older People pilots and Sure Start), the mainstream way of doing things is much more resistant to integration. Delivering the benefits of integration can be made to sound very easy, but it requires a huge commitment to a programme of change and there will be daily distractions and pressures in the way.

However, this guide cannot be neutral. It makes the case for integration, and its purpose is to help it into practice everywhere. Beneficial progress has been made all over the country in co-ordinating services over many years, but the limitations and frailty of such arrangements are clear, and the more robust and sustainable benefits of the integrated approach have now been demonstrated. Furthermore, failure to make progress locally is inexcusable: why should, say, organisational inertia, lack of leadership or professional protectionism be allowed to stand in the way of efficiency and quality gains that can be experienced directly by users? The public expects and needs the key public sector organisations and their strategic partners to lead the way to a better response.

So let’s start with a clear picture of the ends in view. In contemplating the benchmarks described on the next two pages, you might like to consider how far they are in place in the mainstream in your locality. Taking your circumstances into account, the rest of the guide will suggest how you might select and focus on what you specially need to do.

Self assessment: some integration benchmarks

assessment of needs ; a common process across all professions and agencies • information freely and easily shared • all roles and contributions understood by others • everyone accountable for making the system work for users • clear arrangements for joint action with the most complex situations or most vulnerable people.

case management ; designated key workers, able to act on behalf of others • easy communication and transitions • shared caseload of the most vulnerable people with planned multi-disciplinary review.

decision making with individual users ; a single process with authority delegated to front line staff and/or to users via individual budgets or other devices • choice, innovation and personalisation of support.

individual case records ; one it-based record system used by all staff • access for users/patients

In Part Two we will suggest some ideas for local action on these and similar topics. They will be grouped under four ‘levels’ of integration:

• community wide governance
• commissioning
• service provision
• practice.

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

Although this quotation emanates from work in Ireland, it represents service user concerns all over the developed world. Parents ‘Olive and Peter’ quoted in Developing a Model for Integrated Primary, Community and Continuing Care in the Midland Health Board , Executive Summary, June 2003.

We have twin girls aged five. Both have a

moderate learning disability. One also has

autism. We’re totally confused with all of

the different professionals and agencies we

have to deal with. The following are some

of the people we see on a regular basis:

gp, counselling nurse, speech and

language therapist, occupational therapist,

psychiatrist, psychologist, teacher,

classroom assistant, opthalmologist,

audiologist and administrators. We’re so

confused sometimes. We don’t understand

the different roles and have so many

appointments that clash. Can nobody or no

system sort it out?

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

In Part One we help you to develop the critical capacity to make good decisions about local integration, based on an understanding of which users will benefit and how services will improve. We also challenge preconceptions about integration and clarify the basic concepts and vocabulary. You are asked to consider where your current policies, practices and services might fit on a continuum of collaboration – a process that will identify potential next steps.

Finally, having introduced some important and enduring messages from research, we urge clarity about the benefits sought for and by service users. All this is designed to highlight where progress might be needed, to identify likely obstacles and to focus efforts on benefits for the public.

Put simply, the Government regards integration as a remedy for the fragmentation of services, which has been identified as a barrier to more effective care. A simpler, more user-friendly system is required, with a greater continuity of services and a single point of access wherever possible. Integration is seen as the means to this end. In this vein, the 2000 nhs Plan called for ‘a radical redesign of the whole care system’; later, the Green Paper Every Child Matters (2004) stated that ‘the Government’s long term vision is to integrate key services within a single organisational focus’.

Government requirements in relation to integration are now much more specific:

By 2008 we expect all pcts and local authorities to have established joint health and social care managed networks and/or teams to support those people with long-term conditions who have the most complex needs. Our Health, Our Care, Our Say (2006). The key feature of an integrated service is that it acts as a service hub for the community by bringing together a range of services, usually under one roof, whose practitioners then work in a multi-agency way to deliver integrated support to children and families. www.everychildmatters.gov.uk.

The integration of services and the work of professionals to deliver better outcomes for the public is therefore a long- established goal. Expectations of improvement are clear, with an emphasis on early intervention, prevention and support at home. These are now being reinforced by new initiatives and reviews which will sustain this nhs Next Steps Review led by Lord Darzi; Putting People First , the concordat between key partners over the future of adult social care; and the dcfs Children’s Plan, Building brighter futures.

1 Agreeing what integration means

policy

Change for Children

Every Child Matters

a g r e e i n g

(^) w h a t

(^) i n t e g r a t i o n

(^) m e a n s

This guide advocates bringing these issues to the fore, and urges you to try to use the vocabulary of collaboration more carefully to help shared meanings to emerge. Confused definitions will complicate things and hold you back. You should also help create the climate for integration in your locality by encouraging staff involved in joint working to think these questions through together.

Defining integration

In its most complete form, integration refers a single system of needs assessment, service commissioning and /or service provision. These arrangements are managed together by partners from health and social care, who nonetheless remain legally independent. They will also need to work alongside service users, carers and the Third Sector to ensure viable and appropriate models of service provision. A partnership is needed to create an integrated system, but a partnership is not the same as integration. This concept will be useful in the project planning process commended in Part Two.

A single system for a particular service, for example, would unite mission, culture, management, budgets, office accommodation, administration and records, and would apply at any level of integration (team, service or organisation). This is absolutely differentiated from an approach which aims to co-ordinate separate systems.

Remember that no-one is tied to a partnership for ever; it can be varied or ended by agreement. This applies even to a Care Trust – which is a local choice and not a statutory requirement like a Primary Care Trust or a Children’s Services Department.

‘laws’ of integration? The guide includes frequent references to the work of Walter Leutz, an American academic who studied integrated care in the USA and Britain, comparing underpinning concepts and developments. In presenting his findings he has proposed five ‘laws’ of integration. They are not truly scientific laws, but, like a Japanese haiku, they provide a lot of meaning in a few words – rather entertainingly, too. Leutz, W (1999) Five laws for integrating medical and social services: lessons from the US and UK. Milbank Quarterly. 77(1): 77-110. In 2005 Leutz proposed a sixth Law (Journal of Integrated Care, Vol. 13 No. 5)

a p r a c t i c a l

(^) g u i d e

(^) t o (^) i n t e g r a t e d

(^) w o r k i n g

Choosing integration over better co-ordination It is acknowledged that better co-ordination, while not the same as integration, can also result in gains for service users. In fact, it has obvious merits:

• it can deliver many, if not most, of the benefits to users of an integrated system
• it can be a positive, facilitating step towards an integrated system. Indeed, a co-ordinated approach, in which service delivery staff form an informal co-operative network to meet user needs, or use integrated care pathways to structure their work, has undeniable potential as a means of overcoming fragmentation. It can also work in the alignment of policy making, commissioning, training and similar management activities. The question is whether co-ordination is possible to sustain and optimise over time. So, one of the key strategic decisions which you will later be encouraged to face is whether any single integrated system is likely to be more suitable than the co-ordination of existing separate activities. In this context, the necessary transition might be described as a progression from fragmentation to integration. An integrated system might be said to demonstrate minimal fragmentation between partners and minimised autonomous action by their staff; but there are many other possibilities, incorporating sustainable degrees of autonomy and a tolerable level of fragmentation. The guide acknowledges the necessary breadth of this spectrum and tries to set it in the context of varying local needs, conditions and outcomes.

fragmentation There is no holistic view of user needs; actions and decisions are arrived at independently and without co-ordination.

co-ordination There is a shared view of user needs: actions and decision making are co-ordinated.

integration Fragmentation between providers and autonomous action are minimised. Working practices come together. Integration is of greatest benefit to those with complex needs.

For a useful discussion of these issues, see “Partnering Through Networks: Can Scotland Crack It?”, Bob Hudson, Journal of Integrated Care , 15.1, February 2007.