Social Work and Integrated Care

Robin Miller

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138484153
• eBook ISBN: 9781351052849
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

Social Work and Integrated Care draws on the latest research, practice and theory to explore integration within both child and adult services. Although all the home nations in the UK view integrated care as a top priority within health and social care policy, many people continue to experience fragmented care. This book sets out the case for integration, considers the evidence of its impact, and discusses the implementation challenges that must be overcome.

Packed full of current examples of integration, from across the UK and internationally, and reflexive exercises which highlight practice issues for social workers, it provides the following key learning outcomes:

• An understanding of what is meant by integrated care and why it is seen as vital to a modern health and social system.

• A knowledge of the expected impacts in relation to improving the experience and outcomes for individuals and their families, addressing inequalities and promoting health and wellbeing and increasing financial efficiency.

• A recognition of the common barriers to integrated care and what such fragmentation can mean for individuals and their families.

• A critical review of key approaches to promote integration and their practical implementation.

• Reflection on the potential contribution of social workers and their own collaborative practice.

Providing a comprehensive and accessible overview of integrated care policies and practice, this book will help prepare social workers for the realities of collaborating with other professions and services. It should be considered essential reading for students undertaking their professional qualification and those who are in practice who are looking to improve their ability to collaborate.

1 Why are we talking about integrated care?

Social workers know that a good quality of life requires the involvement of many people. This is primarily about the personal networks derived from family, friends, localities and communities of choice that provide emotional and practical support. Social work is about helping people to recognise and draw on the assets within such networks and to contribute in a relationship of reciprocity. For those who do not have strong informal networks, or face challenges of such scale that networks are not sufficient, then formal services can be necessary. These challenges may be related in part to a long-term disability, experiences of abuse or neglect, frailty or a mental health problem but will also have their roots in the multiple and enduring inequalities and discrimination with our societies. In the ideal welfare state, services to help with these challenges would be personalised and flexible so that the support is sufficient to what that person and their network requires to respond to the challenge. This would involve the services and the professionals who work within them being able to work constructively and seamlessly with the other services and professionals involved. All of us would want to provide and indeed receive support in which there are not gaps and uncertainties in what will be delivered and how it will be arranged.

Social workers also know that it is common for people not to receive person-centred and coordinated care. Most social workers will encounter on a daily basis examples of fragmentation between services: child and adolescent mental health services not responding to concerns from schools about the welfare of a pupil, hospital consultants not communicating with general practitioners about discharge arrangements for an older person, community psychiatric nurses not engaging with a housing support provider around a tenant’s mental health. This leads to distress, frustration and anxiety for people and their families that add to the existing challenges. At its most serious, they can result in someone being left at risk of serious harm and abuse and their difficulties escalating to crisis point. As a social work professional this is also incredibly frustrating with precious time being lost which would be better spent positively engaging with a person and their family. The process of chasing, negotiating and in some cases advocating with other services is often stressful for the social worker concerned. Even more so then for the person whose needs are not being met and whose current and future wellbeing is affected. And sometimes it will be social work itself that can be the source of fragmentation.

The current focus in Northern Ireland, Scotland, Wales and England on integrated care is therefore something that should be welcomed by social workers. It reflects a global recognition of the harm that can be caused by services not being sufficiently coordinated and professionals not collaborating around the needs of individuals and families. In 2016 the World Health Organisation formally adopted a framework for integrated, person-centred health services. This highlighted that siloed health and care services ‘undermines the ability of systems to provide universal, equitable, high-quality and financially sustainable care’ and that it resulted in people being ‘unable to make appropriate decisions about their own health and care, or exercise control over decisions about their health and that of their communities’ (WHO 2016, p1). The framework statement later suggests that an integrated and people-centred approach to health and care services is ‘crucial’ if they are to respond to challenges such as ‘global tendency towards unhealthy lifestyles, ageing populations, … multi-morbidities … rising costs’ (p2). Similarly the European Commission stated that to break the ‘vicious cycle of ill health and poverty’ there must be ‘multi-sectorial collaboration … in order to shape the social determinant of health’ (European Commission 2017, p21). This will include health and care working with organisations responsible for education and training, labour market, transport and food policies.

This realisation of the benefits of integrated care (and the damage of fragmented care) is however not new. Studies as early as 1969 by the University of Glasgow report that in relation to health and care of older people ‘the development of each service was usually considered in isolation and that it could not be said that that there was an overall plan for the development of services’ (Sumner & Smith 1969, p348). It suggests that a ‘significant bar to co-operation was the division of responsibility without a clear-cut division of function. Too often this led to failure to develop a service because each side could argue that the other should do it’ (p310). It is worth noting that at this time local authorities were responsible for community health services, so these disputes were often with the same organisation. Later in the book we will reflect on why it is has been so hard to translate this aspiration into reality (Chapter 3). In this chapter we will consider in more detail as to why integrated care is seen as a priority for all the home nations of the UK (and indeed in other parts of the world). We will conclude by reflecting on why this focus on better integration is of particular interest to social workers.

Think of a time when you required information and/or support from more than one organisation or service to achieve your objectives and/or cope with a difficult situation. This may relate to a health, social or educational issue, or something completely different such as planning a wedding, organising a house move or arranging to travel independently. What was important to you regarding the interaction with the various agencies and other people involved?

People tell us that integration is important

A continuing debate within public services, including social work, is how we define their overall purpose. This can seem a somewhat abstract discussion as surely the point of public services is to address the challenges that people face. However, we know from research that setting a clear expectation on what should be achieved is a vital starting point to prioritising how resources should be used and assessing the impact of any service. An important development in recent years has been the emphasis on the purpose being based on the outcomes that are achieved. This contrasts with previous decades in which the focus was on the amount and type of the service that was delivered. It used to be common that specifications would provide targets for the number of people to be supported, the types of interventions that would be available and the staff that would be employed rather than what difference the services had actually made to the people concerned. An example of this new way of thinking can be seen in the statement in 2006 by the Scottish Executive that ‘Our national priorities must be about outcomes – the real improvements that people see in their communities and in their lives – better health, reduced crime and anti-social behaviour, an improved environment and increased educational attainment’. Similarly the Welsh Government (2017a) has defined its long-term aims in relation to what difference this will make to people and communities – ‘prosperous and secure, healthy and active, ambitious and learning, and united and connected’. These are supported by a national framework which outlines the outcomes that would be expected to be achieved for people who need care and support, and carers who need support (Welsh Government 2016). Outcomes thinking has now permeated from policy to the planning and delivery of services, including how they are monitored and evaluated (see Box 1.1).

Box 1.1 Inputs, outcomes and impact (Miller 2011)

Term	Definition
Inputs	All the resources a group needs to carry out its activities
Activities	The actions, tasks and work a project or organisation carries out to create its outputs and outcomes, and achieve its aims
Outputs	Products, services or facilities that result from an organisation’s or project’s activities
Outcomes	The changes, benefits, learning or other effects that result from what the project or organisation makes, offers or provides
Impact	Broader or longer-term effects of a project’s or organisation’s outputs, outcomes and activities

Another positive development is a recognition that people and families should be able to define the outcomes that are important to them. This again is a shift in thinking as previously it was professionals, managers and politicians who were seen as best able to decide ‘what success would look like’. For example, in health care services there was more weight given to ‘clinical outcomes’, i.e. the outcomes that health care professionals have defined as being the expected benefits of an intervention or treatment. This meant that someone may have their health issue dealt with to the satisfaction of the doctor or nurse but still be left with a poor quality of life. Such health care measures are relevant as the professional will be able to identify aspects of a condition that are not understood by a lay-person but they are increasingly accompanied by measures of what matters to the individual concerned.

Social work and social care have been at the forefront of outcome-based approaches with many policy developments emerging from this sector. This includes ‘co-producing’ responses to challenges so that the objectives and offer relate to what people see as important and ‘personalising’ services so that the person is at the centre of care planning and delivery. These have led to governments investing more energy into understanding what people actually want from public services and their experience of receiving such support. Research has highlighted that such outcomes can be themed into three distinct areas (Glendinning et al. 2006):

Quality of life outcomes (or maintenance outcomes) are the aspects of a person’s whole life that they are working to achieve or maintain.

Process outcomes relate to the experience that individuals have seeking, obtaining and using services and supports.

Change outcomes relate to the improvements in physical, mental or emotional functioning that individuals are seeking from any particular service, intervention or support.

Integrated care is a core element of achieving what people want from services (Box 1.2). Services being ‘joined up’ or coordinated is commonly highlighted when people are asked about process outcomes (Ellins et al. 2012). For example, have the professionals communicated about their individual assessments, are there multiple care plans with no overarching plan, and do the different interventions and support complement, duplicate or even conflict with each other? Beyond experience, many people will not be able to achieve what they want in relation to ‘quality of life’ or ‘change’ outcome without successful integration of services around them. For example, for someone with a severe mental illness to be able to leave hospital after a time of crisis may require them securing somewhere to live, restarting benefits or employment, contacting previous networks, and engaging with new professionals and services. All of this requires coordination and communication to ensure that the necessary support is available at the right time.

Box 1.2 What people value from services

A comprehensive review of integrated working found that the aspects which are most valued by people accessing health and social care services include – responsiveness to their needs, relationships and partnerships with named key workers, communication between agencies, accessible information about complex systems, and care planning. It concludes that people and carers are less interested in the configuration of services but more how their own needs are addressed (Cameron et al. 2014).

A review of the evidence of ‘what works’ in supporting young care leavers’ successful transition to independent living summarises that many such young people believe that services are not relevant to their situation, are bureaucratic and complex and will not treat them with respect or respond to their needs. It emphasises that to successfully leave care, planning should begin early, involve young people and those who support them and be collaborative. Continuity of workers helps to provide stability and security with achievements in one area of life giving confidence that there can be success in other areas too (Fauth et al. 2012).

The charity National Voices engages with people who access services, family carers, professionals and others to understand what is important from the perspective of people and their families. Their work has led them to conclude that people ‘expect professionals to work together as a team … and they want services to work together likewise … to meet people’s needs in the round’ (National Voices 2012, p1). They have found that those who rely on multiple services in particular consistently say that they are looking for the system to both know them as a person and have knowledge of all the relevant supports and interventions to respond to their social circumstances and other conditions. Working with Think Local Act Personal (a national partnership in England of more than 50 organisations committed to personalisation and community-based support) they have developed a narrative of person-centred and coordinated care. This is now being accepted internationally as the standard by which we should assess the quality of integration (National Voices 2013): ‘I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring ...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Acknowledgements
• Key terms
• 1. Why are we talking about integrated care?
• 2. National policies for integrated care
• 3. Theories to understand integrated care
• 4. Evidence of integrated care
• 5. Integrating around individuals
• 6. Integrating through professionals
• 7. Integrating across a system
• 8. Where next for integrated care?
• Index