Factors that promote and hinder joint and integrated working

By Ailsa Cameron, Rachel Lart, Lisa Bostock and Caroline Coomber

Key messages• This is an update of a previous systematic

review on the factors that promote andhinder joint working between health andsocial care services. It demonstrates somepositive outcomes of such an approach forpeople who use services, carers andorganisations delivering services.

• Three broad themes are used to organisethe factors that support or hinder joint orintegrated working: organisational issues;cultural and professional issues; andcontextual issues.

• There is significant overlap betweenpositive and negative factors, with many of the organisational factors identified in research as promoting joint working also being identified as hinderingcollaboration when insufficient attention is paid to their importance.

• Securing the understanding andcommitment of staff to the aims anddesired outcomes of new partnerships iscrucial to the success of joint working,particularly among health professionals.

• Defining outcomes that matter to serviceusers and carers is important. Outcomes

defined by service users may differ frompolicy and practice imperatives but are acrucial aspect of understanding theeffectiveness of joint or integrated services.

• Although most service users and carersreport high levels of satisfaction, more canbe done to involve them in care planningand influencing future care options. Jointand integrated services work best whenthey promote increased user involvement,choice and control.

• The evidence base underpinning joint and integrated working remains less than compelling. It largely consists ofsmall-scale evaluations of local initiativeswhich are often of poor quality and poorlyreported. No evaluation studied for thepurpose of this briefing included an analysisof cost-effectiveness.

• There is an urgent need to develop high-quality, large-scale research studiesthat can test the underpinning assumptionsof joint and integrated working in a morerobust manner and assess the process fromthe perspective of service users and carersas well as from an economic perspective.

May 2012 Review date: May 2015

41RESEARCH BRIEFING

Factors that promote and hinder jointand integrated working betweenhealth and social care services

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IntroductionThe aim of this research briefing is to give peoplewho provide and use social care services anoverview of the research evidence for joint andintegrated working by identifying andsystematically describing:

• different models of working between healthand social care services at the strategic,commissioning and operational levels

• evidence of effectiveness and cost-effectiveness

• factors promoting and obstacles hindering thesuccess of these models

• the perspectives of people who use servicesand their carers.

This briefing updates a previous systematicreview by Cameron and Lart1 that reported on thefactors that promote and hinder joint workingbetween health and social care services. Giventheir prominence in terms of policy debatesabout joint and integrated working, the briefingfocuses on jointly-organised services for olderpeople and people with mental health problemsin the UK only. In line with the original review,papers have only been included in this briefing if:

• they refer to an actual, rather than proposed,model of joint working

• they include primary data

• an evaluation of the model has been carried out.

Papers reported evaluations published before2000 have been excluded from this briefing butpapers published before are reported in Cameronand Lart. Taken together, the findings provide a30-year overview of UK-based evaluations of jointworking in health and social care. Please note that‘joint working’ is used as an umbrella term todescribe all models of working together, with‘integrated services’ used only to refer to healthand social care services that have been merged.

What is the issue?A consistent theme of policy over the past 40 years has been a concern that welfare services

RESEARCH BRIEFING 41

could be improved if statutory agencies workedtogether more efficiently. In the field of adulthealth and social care a variety of strategies havebeen introduced to encourage or direct agenciesto work together. In England, Wales andScotland, the 1970s saw policy-makers focus ondeveloping mechanisms by which health andlocal authorities jointly planned services. In the1990s attention focused on efforts to overcomethe fragmentation of responsibilities for adultsocial care2 as well as on the introduction ofinitiatives (e.g. intermediate care services)conceived to improve the coordination of servicesin order to better support people making thetransition between acute, primary and socialcare.3 In Northern Ireland, the structure ismarkedly different from the other countrieshaving structurally integrated health and socialcare services in the 1970s. Since 2009, the healthand social care board is responsible for planningand commissioning, with services for NorthernIreland’s population of 1.7 million peopledelivered via five health and social care trusts.

Under the previous Labour administration, therewas a drive to improve joint working.4 Initially,attention focused on the introduction ofmechanisms to assist partnership workingbetween health and social care services. TheHealth Act 1999 attempted to remove some ofthe obstacles that were perceived to hinder jointworking − for example, allowing statutoryagencies to pool budgets and jointly commissionservices − as well as to provide the legalunderpinning for further integration.5 Thegovernment in England then set out an agendacalling for greater structural integration of localauthorities and primary care services, whichincluded the establishment of care trusts. Mostof these new trusts were specialist mental health, physical or learning disability partnerships and involved the organisationalintegration of health and social care services.7The previous Labour government also introducedspecific mechanisms such as the singleassessment process (SAP) to improve jointworking at the frontline.8

The present Coalition Government has continuedthis policy. The 2010 White Paper Equity and

excellence: liberating the NHS set out theGovernment’s aim to ‘simplify and extend theuse of powers that enable joint working between the NHS and local authorities’ in orderto make it ‘easier for commissioners andproviders to adopt partnership arrangements,and adapt them to local circumstances’. TheWhite Paper makes clear the government’sintention to ‘unlock efficiencies’ that areperceived to exist within the existing system.6A vision for adult social care9 further emphasisesthe Government’s intention to identify andremove barriers preventing the pooling ofbudgets between health and social care, whilealso encouraging the involvement of small social enterprises and user-ledorganisations in the provision of social care.

Why is it important?While the specific focus of policy-makers’interest in joint working has changed over time,the reasons for this interest have remainedconsistent. Rising demand for services, coupledwith the need to reduce public expenditureprovide compelling arguments for greatercollaboration in the UK.10 Additionally, theintegration of health and social care servicespotentially offers further means of supportingpeople with complex needs to live independentlyin the community.11 However, the questionremains whether or not reforms over the pastdecade have been successful in meeting theobjectives set out by policy-makers.

About this research briefing Our previous review of the research literatureconcluded that while it had a lot to say about theprocess of joint working, very little attention hadbeen paid to exploring the effectiveness of thisapproach, either for service users and carers orfor the organisations providing services.1 Thisresearch briefing provides an update. Themethods used to identify and organise materialin this briefing were developed by the Social CareInstitute for Excellence (SCIE), and includedundertaking systematic and reproducible

searches of the literature. The briefing aims toprovide a signpost for further reading, rather than a definitive account of ‘what works’. Asnoted above, we sought out UK-basedevaluations of jointly-organised services for olderpeople and people with mental health problemsonly. It is based on papers published in peer-review journals only. Forty-six papers wereidentified, reporting 30 separate studies. Themajority of studies (22) evaluated services forolder people while six looked at mental healthservices and two examined services for botholder people and people with mental healthproblems.

Interestingly, categorisation of the papers by dateshowed that almost all the studies pre-dated2009, and the majority of them (37) werepublished before 2007. Additional steps taken by the review team to ensure that no evaluationstudies published after 2008 had been missedresulted in just one further paper from 2010being included.12 The final list of papers forinclusion was independently reviewed.

This suggests that the evidence base is laggingbehind current policy and practice. Reviewersspeculate that this deficiency reflects policypriorities in England linked to the introduction ofthe Health Act 1999, and other initiatives such asthe establishment of community mental healthteams (CMHTs), and the introduction ofintermediate care priorities that may have movedonto the implementation of personalisationfollowing Putting people first.13 Papers in peer-reviewed journals from the Partnerships for Older People Projects (POPPs) evaluation are yet to report.14

This means that this briefing cannot comment onthe impact of personalisation on joint working orchanges introduced by the Health and Social CareAct 2012. However, it is based on a systematicassessment of the existing evidence base and itsmessages are crucial to the development of newjoint working initiatives such as clinicalcommissioning groups and health and wellbeingboards, providing a solid base from which toconsider the factors that promote and hinderjoint work.

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Factors that promote and hinder joint and integrated working between health and social care services

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What does the researchshow?Models of joint workingOur emphasis was on UK-based evaluations ofjointly-organised services for older people andpeople with mental health problems. Within thisarea research is overwhelmingly focused onfrontline services and service delivery. Studies fallinto the following categories:

• multi-agency teams

• placements of individual staff across agencyboundaries

• co-locations of staff that were not formal teams

• SAP

• the provision of intermediate care

• structurally integrated services

• use of pooled budgets.

Allowing for policy developments such as theintroduction of SAP, intermediate care andpooled budgets, this is similar to the pattern wefound in our earlier review.1 Almost no studiesfocused solely on strategic-level joint working,with the exception of one that explored the useof pooled budgets.2

‘Teams’The largest category of models was ‘teams’.However, this term covered a range of services andorganisational models. Within mental health theteams were almost always CMHTs, characterisedby the inclusion of staff from both health andsocial services.15–25 However, two studies looked atspecialist teams: crisis intervention and assertiveoutreach,15 and a ‘memory service’.26 In servicesfor older people, teams had a range of functions,from rapid response, assessment and careplanning, to direct provision of services, includingtime-limited intermediate care, both at home andin specialist residential facilities.26–29 One studycompared two teams, one from mental health andone from older people’s services.30

Teams varied in the extent to which they couldbe described as ‘integrated’. Key elements ofintegration included having shared processes

such as assessment and allocation, sharedinformation and records, common managementand at least some common activities or skills. Atthe other end of the spectrum were teams whichhad some or all of the following:

• distinct lines of management

• separate allocation and assessment

• separate information systems, keptconfidential from each other

• clearly defined and maintained professionalboundaries.

Not all studies provided enough informationabout working practices and arrangements todetermine where the teams fitted on thespectrum.

Few team studies were comparative, describingonly a single team. Those featuring comparisonscompared integrated teams with more traditionalways of working. The set of five papers bySchneider et al.20–22 and Carpenter et al.23–24

report on a complex study of CMHTs, comparingfour districts that had fully implemented the careprogramme but organised their servicesdifferently. The teams differed in terms of whetherthey were ‘integrated’ or ‘discrete’ in terms of jointworking: two mental health trusts worked closelywith the local social services department(‘integrated’) and two worked independently(‘discrete’). A further difference was whether theysaw a broad range of clients (‘inclusive’) or focusedon people with severe mental health problems(‘targeted’), giving a comparison of four possiblepermutations of these variables: discrete andtargeted; discrete and inclusive; integrated andtargeted; integrated and inclusive.

Rothera et al.18 reported on a multi-agency home care service working with older people withdementia, and compared this to a standardservice. Brown et al.27 compared an integratedhealth and social services team, responsible forthe delivery and management of community careto older people, with traditionally organisedservices. The study by Huby and Rees30 looked attwo sets of teams at either end of the spectrumof integration, working with completely different


client groups: CMHTs and rapid response teamsfor older people.

Taking the studies as a whole, few provide muchdetail about the organisational models beingused for team working, and few have strongevidence about the impact on service users andtheir carers of joint working. Probably thestrongest evidence is that of Schneider et al. whoconsider the different impacts of ‘integrated’ asopposed to ‘discrete’ organisational models inmental health.

Placement schemes and co-locationThe next biggest category of models reportedwas placement schemes: arrangements wherebystaff from one agency are placed in a setting runby another,31–33 or where staff from acrossagencies are co-located but do not constitute aformal team.34 These were usually social workstaff placed in health settings, but one case ofhealth staff working in a social services daycentre for older people was also reported.35

Several of the arrangements were early forms ofmulti-disciplinary team, and most of the studiesdated from the early part of the study period.Perhaps unsurprisingly, many of the same issuesdescribed above relating to degrees of realintegration in multi-disciplinary teams applied tothese arrangements.

Single assessmentFour studies looked at processes for theintegrated health and social care assessment of older people. In three of these, the modelincluded the addition of assessment by a clinician to that by a care manager,36–38 while inthe model investigated by Christiansen andRoberts,39 district nurses based in generalpractitioner (GP) surgeries were enabled to carry out social care assessments and go on tobecome care managers.

Structural integrationThree studies looked at examples of thestructural integration of health and social careservices. One was a comparison of the degree of integration found in assessment and caremanagement processes in Northern Ireland and England,40 while in the two others the

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settings were integrated health and social caretrusts in England.41–46

‘Intermediate care’ for older peopleA further group of studies reported onarrangements for intermediate care for olderpeople: services designed to provide either analternative to hospital care or a bridge betweenacute hospital care and normal community healthand social care. In some cases these overlappedwith the category of ‘teams’.47–49 Trappes-Lomaxet al.50 compared the use of a residentialintermediate care unit with traditional communityhealth and social services. A set of three papersreporting the national evaluation of intermediatecare51–53 describe case studies of this type of carefrom several different methodologicalperspectives. However, the central issues of jointworking seem to be about the relationshipbetween acute and community services, ratherthan that between health and social care.

Pooled budgetsOne study looked at the experience of usingpooled budgets as a result of the flexibilitiesintroduced by the Health Act 1999, to enablecollaboration between health and social care in England.2 In this case the comparison was with arrangements in Sweden. The study lookedat a range of case studies covering differentservices, budget sizes and organisational models.The published paper does not give details of thecase studies included, but draws out generalthemes arising from the use of the flexibilitiesallowed by the Act.

Effectiveness of joint working

Assessing effectiveness is based on theevaluation of how a policy or other interventionis implemented, the effects it had, for whom,how and why.54 However, not all the evaluationsincluded in this briefing reported data in this way. Some studies are highly descriptive,providing no clear data on effectiveness,29,37

and others do not define specific outcomemeasures, with the result that reviewers have had to distil them from papers16,17,29,32,35,39,40,46,47

or report outcomes that are unrelated to theevaluation.49 Few are comparative in design or

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offer a before-and-after analysis following theintroduction of a new service. This makes itdifficult to assess whether or not an intervention has been a success. In other words,did it make a difference to the health andwellbeing of people using the service? Was theservice accessible and acceptable? Whatoutcomes mattered to service users?

This difficulty is compounded by differences inthe models of joint working, the range of working practices and arrangements identified,the variety of standardised measures used,differences in study design and the complexities of comparing services in two large and heterogeneous service user groups(older people and people with mental healthproblems). However, trends in the data areevident and in this briefing have been groupedaround clinical outcomes, service provision andimpact on staff satisfaction and stress. Serviceuser and carer perspectives are reportedseparately.

Clinical outcomesImprovements in quality of life, health, wellbeingand coping with everyday living are reportedacross a number of studies.26,36,47,52 However,where evaluations are based on a comparativedesign which assesses different types of jointworking, including integrated and non-integratedcare, no significant differences or only marginaldifferences were reported.19,24,27,34,50 The complex study of CMHTs by Schneider et al.21

found few differences in quality of life between‘integrated’ and ‘discrete’ districts. Wheredifferences were identified, service users inintegrated districts socialised more and had lessdifficulty accessing police and legal services. Intheir study of the effectiveness of a jointNHS/social services rehabilitation unit for olderpeople on discharge from community hospital,compared with ‘usual’ community services,Trappes-Lomax et al. comment that ‘results forthe two groups are strikingly similar’.50 Thesefindings are not explained however. Otherauthors suggest that this may reflect a mix ofreality at the frontline,21 service usercharacteristics34 and the fact that the integratedservices being assessed had not been fully

implemented.19,27 Equally, it may simply be theresult of the study design itself: the instrumentsused may have been insufficiently sensitive tochange over time, or the time period may havebeen too short to capture change.21

Avoiding inappropriate admission to acute or residential careThe reduction of inappropriate admissions toacute or residential care has been identified aspart of the role of intermediate care.48,49,52

Small-scale studies of rapid response teamssuggest that their provision of health and socialcare services in the community has an important role in supporting people to remain in their own homes. In Brooks’ study49 of a newintermediate care rapid assessment supportservice, just four (5 per cent) of all the olderpeople using the service were admitted to anacute hospital. Making a similar point, Beech48

uses staff estimates to suggest that 92 per centof referrals would have remained in the acutesetting without the intervention of intermediate care.

Remaining independent at homeThe organisation of a service does not appear to improve the likelihood of service users beingable to live in the community; rather, need andaccess to support at home are key factors.Clarkson et al.36 found that although anintegrated assessment completed by specialistclinicians and social services care managersreduced the overall risk of care home admission,‘the intervention increased the risk of care home[i.e likelihood] entry for the frailest individuals, a positive effect of targeting’. Two separatestudies that compared outcomes for older people using a new integrated health and socialcare team with those served by a moretraditional model of service found no statisticalsignificance between the two.27,34 Davey et al.34

found that an older person’s score on the Mini-Mental State Examination (MMSE) was themost influential predictor of whether they wereable to remain at home, followed by home care hours and living with others. Co-locationbetween health and social care services was notsignificant as a predictor of whether a personremained at home.


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supervision aimed at ensuring a social workcontribution to multi-disciplinary working wasalso noted. In Gulliver et al.’s final evaluation ofthe first fully integrated health and socialservices mental health trust in England44 it wasfound that while role clarity and morale gotworse for 18 months following integration, thesereductions were levelling off and in some casesreversing after two years. This reflectsimprovements in the team environment, withproximity improving communication and staffwelcoming the opportunity to learn new skills.However, boundaries between professionalscontinued to exist within community teams andother services, particularly the acute sector.

Costs and cost-effectiveness

Assessing the costs and cost-effectiveness ofjoint working is hampered by a lack of economicevaluation evidence, evidence that isdated19,22,31,32,47,55,56 and the diversity ofapproaches to integrating services. No evaluationincluded an analysis of cost-effectiveness, andthis lack of evidence meant that Ellis et al.56 wereunable to carry out their proposed investigationand provided a resource utilisation analysisinstead. They compared a joint NHS/socialservices rehabilitation unit for older people ondischarge from a community hospital with ‘usual’community services. Overall, they found that thecosts were almost identical between the twogroups. This finding is echoed in almost all otherstudies that compared integrated serviceprovision with standard care.19,31,34,36

There is some evidence that intermediate carecan be cost-saving.47,52 Kaambwa et al.52

studied the cost of five intermediate careschemes in relation to health outcomes for older people and found that, compared withthose admitted as part of a supported discharge scheme, those who were admitted aspart of hospital avoidance schemes experiencedgreater gains on both the EQ-ED and Bathelindices. Importantly, hospital avoidance services were also associated with lower cost, with amean episode (29.5 days) costing on average£1,200 compared with £1,500 for supporteddischarge cases.

Service provisionSurveys and interviews with staff identified arange of service developments that were believedto have improved provision. These included:

• rapid referral and assessments16,39

• increased flexibility, responsiveness andadopting a proactive approach to individualcircumstances and requirements16,18,32,53

• the benefits of a single point of access39,53

• a single key worker24

• improved communication and coordinationbetween agencies16,46

• access to pooled knowledge and resources16,24

• the opportunity to be more service user-centred.16,53

In Sutcliffe’s before-and-after study38 of theintroduction of SAP in three areas, significantlymore multi-disciplinary assessments were foundto be undertaken after the introduction of SAPthan before. Where multi-disciplinary teamsworked well, opportunities to discuss concernswith colleagues from different disciplines, seekback-up and agree a plan of action werewelcomed and afforded ‘more considered butpotentially less conservative decisions’.17

Service organisation, staff satisfaction and stressThe effects of service organisation on staffsatisfaction and stress were explored byCarpenter et al.23 who found that there weresystematic differences in team functioning,favouring teams in districts where mental healthand social care services were integrated.However, service organisation had no evidentimpact on professional or team identification oron outcomes for staff in terms of stress or jobsatisfaction. This appeared related to roleconflict, with social workers reporting poorerperceptions of team functioning and experiencinghigher levels of such conflict.

Controlling for other factors, role conflict was asignificant predictor of stress and jobdissatisfaction, while role clarity promoted jobsatisfaction. The importance of support and

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However, while intermediate care patients whohad been admitted to avoid hospital incurredhigher costs − patients in residential settings cost more than three times as much as those innon-residential settings (£2,784 versus £879 per patient) − the authors point out that thesepatients would otherwise be occupying a hospitalbed and so hospital costs are avoided. It shouldbe noted that many of those receivingintermediate care would have simply stayed athome or gone home from hospital without suchcare. In other words, the new service could bedescribed as an ‘add on’ – good for people whogot it but sometimes providing additional ratherthan alternative services.

Service organisation, use and costsSophisticated analysis of costs across four districtsproviding community mental health servicesilluminates the impact of service need − ratherthan service organisation − on costs.22 As notedabove, the study by Schneider et al. compared fourdistricts that had fully implemented the careprogramme but organised their services differently.Two mental health trusts worked closely with thelocal social services department (‘integrated’) andtwo worked independently (‘discrete’). Two saw abroad range of clients (‘inclusive’) and two focusedon people with severe mental health problems(‘targeted’). While people who were most likely touse social care lived in a district that was bothintegrated and inclusive, when the amount ofservices used (costs) were measured, there was agreater degree of service consumption in targeteddistricts. This is true for community mental healthservices and for social services, and consequentlyfor costs in targeted districts. In other words,differences in costs reflect case mix, with servicestargeted at people with severe mental healthproblems increasing costs by 50 per cent.22

Integrated districts were found to be no morecostly than discrete districts. Indeed, there wereindications that when taking health and socialcare costs together, integrated districts may beless costly. However, the authors conclude thatsince both targeting and integration areincreasingly common mental health policies, it is important to recognise that they may haveopposing effects on costs.

Where costs fall – health and social care agenciesCosts can fall differently on different partners.Investing in community services to reduce thecost of acute care is dependent on being able torelease potential savings in practice. In theintegrated districts, described above, socialservices bore a larger share of costs. In targetedareas, costs borne by health services weresignificantly higher. In the district that was bothintegrated and inclusive, there was a more equalshare of the costs because the care manager also acted as a key worker. This ‘see-saw’ effectwas noted in one other study: Ellis et al.’sinvestigation56 of a joint NHS/social servicesrehabilitation unit. Here it was found that thecost of the unit option fell more heavily on socialservices (£5,011.56, compared to £3,530.72 tothe NHS), whereas the community option fellmore on the NHS (£5,146.74, compared to£3,363.94). The difference in NHS costs waslargely due to the control group’s longer stay inhospital (costing £2,080.87 on average perperson compared with £883.03 for theintervention group). The difference in socialservices was mainly due to the cost of therehabilitation unit (a mean cost of £1,503.37).

Where costs fall – service users and carersThe costs of unpaid or informal care were almostnever included in cost studies, and yet the unpaidcare provided by friends and relatives and thetime costs to service users themselves can have amajor bearing on the potential cost-effectivenessof health and social care interventions. It issignificant that Schneider et al.22 noted thatproductivity losses for service users and carerswere not included, since their study was primarilyinterested in the cost to providers of differentforms of service organisation.

Only one study offers us a rare insight intoinformal costs. Clarkson et al.36 re-analysed datacollected from a randomised controlled trial ofan integrated assessment for older peoplecompleted by specialist clinicians and socialservices care managers. They included informalcosts, in terms of ‘personal consumption’ (notexplained) and housing costs incurred by carersand the older people themselves. For the frailest


way to ensure that policies and proceduresunderpinning new initiatives are widely understoodand that staff are competent to complete newprocedures − for example, if new types ofassessment are required.18,26

However, it is equally important that there is asimilar understanding of roles and responsibilitiesat the strategic level. For example, having acomprehensive service-level agreement drawn upto underpin the placement of social workers inGP practices enabled agencies to identifyrespective responsibilities for the initiative.32

Similarly, Drennan et al.28 highlight theimportance of having clearly specified referenceterms and membership criteria for projectsteering groups and/or management groups aswell as an explicit operational plan. Ensuring that there are clear frameworks, both legal andfinancial, underpinning the establishment ofpooled budgets was identified as beingsupportive of partnerships.2 Equally, strategiccommitment at an executive level to devolveresponsibility has been identified as important tothe outcome of joint initiatives.32

Flexibility in relation to work roles was reportedto be beneficial in a number of studies.19 Regen et al.53 note that flexible roles supported theaims of intermediate care services and thathaving a flexible approach to the organisation ofwork in specialist multi-agency teams wasthought to improve the responsiveness of theservice, ensuring that the needs and preferencesof older service users were met.18

The development of new integrated roles wasalso identified as being supportive of jointworking.27,29 Staff working in integrated teamsreported less role conflict and fewercontradictory demands than those working inother types of team. They also consideredintegrated teams to be more innovative andsupportive of new ideas.23

Past history of joint workingA previous history of strong and supportive localpartnerships was identified as an importantfactor in the success of joined-up services.16,37,47

For example, Taylor29 notes how a previous

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individuals, the integrated assessment led toincreased costs for the NHS and social servicesbut a reduction in costs to older people and theircarers. However, for those with severe cognitiveimpairment, the integrated assessment reducedNHS and social services costs while raisinginformal costs. The authors offer no explanationfor these effects but they may reflect admissiondecisions by clinicians and social servicesmanagers. The views of service users and carersare not included.

Factors promoting joint working

It became clear that the three broad themesidentified in the original systematic review werestill valuable as categories under which toorganise the factors that supported or hinderedjoint working. These themes were organisationalissues, cultural and professional issues andcontextual issues. Within these overarchingthemes, new areas of interest emerged.

Organisational issues

Aims and objectivesEnsuring that professionals and agencies involvedin new initiatives understand the aims andobjectives as well as the detail of the eligibilitycriteria and referral processes is important to the success of any new initiative. One way todevelop a common understanding is to involvestaff in the development of the policies,procedures and protocols underpinning theservice.47 Additionally, professionals who are notpart of the core partnership (e.g. those working inreferral services) need to understand the eligibilitycriteria if the initiative is to succeed.26 Providingintroductory as well as ongoing training wasidentified as a constructive way to ensure that acommon goal is established among partners.27

Roles and responsibilitiesAt an operational level it is important that allparties involved in a new joint initiative understandthe roles and responsibilities of those involved, andsuch understanding is thought to lead to betteroutcomes.27 Such responsibilities include themanagement of budgets, administrative supportand the coordination of material resources.32 Onceagain the provision of training was identified as a

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history of joint working between GPs, districtnurses and home care managers enabled a newinitiative to build on existing informal processesof communication and capitalise on the goodwill that the previous experience hadfostered. Positive relationships at a strategiclevel, for example that in the past may have been between county council and healthauthority staff, were also seen to be supportive of integrated working.

CommunicationEffective communication was reported toenhance joint working in a number ofstudies.16,18,27,46 For example, informal and opencommunication within a multi-disciplinary teamwas thought to be valuable in supporting anewly-established venture,16 and improvedcommunication associated with integratingservices was perceived to lead to improvedoutcomes for people using services.36

Information sharingEffective mechanisms to share information,including shared documentation and shared orcompatible information technology systemswere factors identified as improving jointworking, leading to speedier and timelierassessments of need.19,27,49 Effectivecommunication was also reported to lead tocases being prioritised more efficiently.32

Adequate resourcesSeveral studies noted the importance of havingadequate funding to support an initiative. Forexample, ensuring that there were resources toprovide holiday or sickness cover for placementschemes (e.g. where social workers practice fromGP surgeries) was an important element of theirsuccess.32 Working in partnership can mean thatagencies have access to additional resources tosupport a venture − for example, it mightincrease opportunities for joint training16 orimprove access to a range of facilities.2 Theexistence of a unified budget was identified as a factor that supported joint initiatives.28

Co-locationCo-location was reported to be an importantelement in the success of joint working. For

example, it leads to greater levels of informalcontact which in turn increases mutualunderstanding.19 It was also reported to lead toquicker and easier communication16 and tofacilitate learning across professional boundaries.15

Strong management and professional supportStrong management and appropriateprofessional support at an operational level werereported to be important elements of successfuljoint working, whether in relation to integratedservices,53 multi-disciplinary teams working aspart of an integrated service,16,47 specificinitiatives such as the introduction of SAP37,39 orplacement of social work staff in a GP practice.32

The presence of strong leadership was thought to contribute to staff feeling more confident intheir new team or role.16,47 Additionally, havingcoordinated leadership between differentprofessional groups within a multi-disciplinaryteam was reported to improve understanding ofthe aims of the initiative.49

Similarly, Rutter et al.19 identified the importanceof having an integrated management structure.Ensuring staff felt supported in their professionalrole was seen to be an important part of effectivemulti-disciplinary working.53 Being able to accessexpertise from a range of professions within theteam was thought to lead to better outcomes forpeople receiving services.36,49 Finally, thecomplexity of joint ventures often meant thatkey individuals played an important role inlinking organisations and cultures, acting as a‘trusted allies’.29

Cultural and professional issuesRegular team-building events were identified as a factor supporting the introduction of newmulti-disciplinary health and social careteams.27,29 Team-building and subsequent weeklymeetings were used to create a common sense of purpose, allocate and discuss cases andprovide an opportunity to share informationwhich supported the functioning of the team.27

Regular team meetings were also seen as ameans to foster understanding about differentprofessional roles, overcome professionaldifferences57 and build trust and rapport betweendifferent groups.29


Contextual issuesNo contextual issues were consistently reportedto be supportive of joint working. However, anumber of interesting themes were identified insingle studies. Asthana and Halliday47 report that the specific context of a locality, in this casethe demographic composition as well as therurality of the area, provided a ‘compelling’reason for agencies to collaborate and develop an intermediate care system. Drennan et al.28

note the importance of ensuring that newservices were linked into the ‘whole system’ − intheir case, older people’s services.

Establishing a new rapid response team wasreported to be a welcome opportunity to make afresh start.30 Integration as such − for example,through the establishment of a combined healthand social care mental health trust − wasreported to improve joint working.40 Finally,Hultberg et al.2 suggest that one of theconsequences of pooling budgets is that it makestransparent the process of resource allocation,thereby empowering organisations to challengethe conventional ways in which services havebeen delivered and enabling more creativesolutions to be explored, while at the same timemaking the process more equitable.

Factors hindering joint working

Organisational issues

Aims and objectivesThe importance of partner agenciesunderstanding the aims and objectives of anyjoint working initiative is central to its success,but establishing a shared purpose can proveproblematic.28 Several of the studies exploring the introduction of intermediate care services and other examples of integrated servicesreported a lack of understanding of the centralaim and underpinning philosophy of theseinitiatives among some health professionals.36,47,51

Without a shared understanding of aims andobjectives, partnerships may struggle to develop a sense of purpose at the operationallevel, and this difficulty is compounded whenthere is little clarity about the lines ofresponsibility and authority for decision-making.28 Without consensus about the aims

and objectives of an initiative it becomes almostimpossible to evaluate progress.

Roles and responsibilitiesA number of studies identified that a lack ofunderstanding about new initiatives or servicescould lead to a lack of clarity about the roles andresponsibilities of the agencies and professionalsinvolved, as well about as the policies andprocedures underpinning the new service or wayof working.

For example, insufficient shared understandingabout the aims of intermediate care resulted in a lack of appreciation of processes such aseligibility criteria and referral.51 The same study by Glasby et al. identified a lack ofunderstanding of professional roles amonghospital and intermediate care staff. A similarshortage of clarity was noted by McCormack et al.46 who report that this resulted ininappropriate referrals and delays in treatment.At an individual level, insufficient appreciation of professional roles in relation to theintroduction of SAP led to confusion andprotectionism among those involved, as well asconcerns about the blurring of professionalidentities.37 Finally, Huby and Rees30 noteconcern about maintaining role boundaries inmulti-agency teams while Rutter et al.19 showthat rigid and inflexible professional roles canundermine joint working.

Organisational differenceAt a strategic level, competing ‘organisationalvisions’ about the joined-up agenda and a lack ofagreement about which organisation should leadwhich ventures appeared to undermine thesuccess of initiatives aimed at joining up servicesin a systems-wide approach, as did the absenceof a pooled or shared budget.53 Differences inresource and spending criteria between localauthorities and NHS partners were thought toundermine the aims of joint working.19 Finally,Drennan et al.28 note how difficult it is to turndivergent organisational agendas into anintegrated operational reality.

At an operational level, differences inorganisational policies hampered joint initiatives.

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For example, different attitudes towards riskmanagement that were evident between GPs andsocial workers led to inappropriate referrals toresidential care,57 while differences in health andsafety policies presented challenges to frontlinestaff working in intermediate care services.53

Additional difficulties were experienced byprofessionals straddling team and parentorganisation boundaries.30 For example, differentfunding streams frustrated attempts to developjoint assessment mechanisms.16

CommunicationCommunicating across professional or agencyboundaries can often prove difficult.Professionals working in integrated servicessometimes struggled to communicate effectively,particularly when they were not located on thesame site. Occasionally these difficulties led todelays or gaps in care and treatment.46 Brooks49

notes that communication within a multi-disciplinary rapid assessment support servicebroke down once an older person was admittedto acute care. This resulted in information notbeing routinely shared with ward staff, therebyundermining the continuity of social worksupport that the service was set up to deliver.49

Information sharingNot surprisingly, difficulty sharing information,lack of access to information, as well asincompatible IT systems were reported as factorsthat undermined joint initiatives.2,19,25,39,53

Additionally, misunderstandings about thesuitability of sharing information electronicallybetween GPs and members of multi-disciplinaryteams supporting older people caused delays inthe setting up of services.28 In a similar vein,professional concern about the logistics andappropriateness of sharing information via thecreation of shared electronic databases wasidentified as a factor undermining jointinitiatives,57 and one study suggested that suchconcerns were most apparent among professionalswith no previous experience of working together.37

While such difficulties were generally reported inrelation to specific services, occasionally they wereapparent at the boundaries between differentsectors and were likewise thought to impedeintegration for similar reasons.46

Co-locationFragmentation of services and a lack ofuniformity in terms of their location meant that in some instances referral processes werecomplex and professionals struggled to respondconsistently and coordinate individualprogrammes of care.46 Interestingly, while moststudies that reported the impact of co-locationwere supportive of the strategy, this view was not universal. In an evaluation of multi-agencyworking, Kharicha et al.57 report that co-locationsometimes led to greater informality, whichcould in turn undermine professional practice.The authors also note that social workers wereconcerned that co-location in a health centreundermined their ability to prioritise the work of their social service employer.

Strong management and professional supportA lack of strong and appropriate managerialsupport was thought to undermine attempts towork across agencies and professional boundaries,leaving practitioners feeling unsupported.25,37

Drennan et al.28 suggest that the absence ofeffective management might reflect a lack ofexperience in collaborative working among someprofessional groups. Additionally, the presence ofseparate management structures was regarded asan undermining influence.19,39

Involvement Whether or not professionals were involved inthe development of new services and ways ofworking affected how such ventures wereperceived and valued.37 Glasby et al.51 report thatwithin intermediate care services a lack ofinvolvement in the initial planning of services bysome professionals (specifically health staff)might have contributed to a perceived lack ofunderstanding and appreciation of these services.They suggest that such a lack of understandingmight lead to an unwillingness to refer patientsinto the service.

Cultural and professional issues

Negative assessments and professionalstereotypesCultural differences between professional groupscan undermine joint working at both the


strategic and operational levels.39 Studiesinvestigating intermediate care noted animbalance of power between community andacute sectors, suggesting that new services mightbecome dominated by the interests of acuteservices at the expense of their partners.51

Similarly, Drennan et al.28 note that culturaldifferences could undermine partnerships andthat, in the absence of clarity about lines ofauthority, strong and weak partners may emerge.

Different professional philosophiesBy its very nature, joint working brings togetherprofessionals with different philosophies andvalues as well as divergent professional cultures.Not surprisingly, these differences can act asbarriers to effective joint working.39,41,57 Forexample, Scragg25 notes a perception that socialwork values, and in particular the social model,were not respected by health professionals andthis led to a lack of appreciation of theircontribution within multi-professional teams.Carpenter23 reports that social workers based insuch teams experienced higher role conflict andmore stress compared to their colleagues. Hesuggests that this was due to a perception thattheir professional values and culture were underthreat when working in a health-dominatedenvironment. Differences in professional culturewere also believed to undermine the introductionof integrated systems, with some professionalgroups appearing not to appreciate or value theaims of integration.36

These professional differences could also affectspecific elements of practice within a jointinitiative. For example, a lack of understandingabout the nature of supervision expected within aparticular profession could result in either a lackof supervision or a duplication of arrangementswithin a multi-disciplinary team.28 Severalevaluations noted distinct professional attitudestowards the appropriateness of shared clientrecords,16 particularly the electronic sharing ofinformation,57 and different attitudes to conceptssuch as ‘risk’ led to divergent practice related tothe discharge of older people.35 Gibb et al.16 notethat health and social care staff differed in termsof the type and level of decisions they couldmake and that they had different lines of

accountability; such differences tended to dilutethe effectiveness of joint working. Integrationwas also associated with an increase inbureaucratic activity, for example requiringprimary care staff to apply eligibility criteria forhome care services, a task they were notpreviously required to perform.29

Trust, respect and controlTrust and respect between professionals is criticalto the success of joint working. The introductionof initiatives such as SAP requires professionals tobe confident with the assessments made by othergroups. However, an evaluation of localimplementation suggests that professionalssometimes lack confidence in, or are mistrustfulof, the assessments made by others.37 This wasmost pronounced when professionals had noprior experience of working together. Glasby et al.51 note that hospital staff were perceived to be reluctant to refer older people intointermediate care because they might ‘losecontrol’ of their patients. In another example,lack of trust in a team manager who came from adifferent professional background led socialworkers to bypass their leader and seek thesupport of their own professional lead.25

Joint training and team-buildingJoint training and team-building events provideopportunities to build relationships betweendifferent professions and agencies as well givingan opportunity to inform professionals aboutnew services and the policies and procedures thatunderpin them. The absence or limited nature ofsuch events was believed to undermine jointworking.37,39 For example, in an evaluation of theimplementation of an integrated health andsocial care assessment, professionals reportedthe need for more training. District nurses inparticular wanted more training related to thepractical skills required to complete theassessment, which included asking aboutpersonal finances − something they had neverpreviously had to do.39

Role boundariesSeveral studies noted the negative impact jointworking can have on professional identity,including role boundaries.30 For example,

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placement schemes appeared to raise concernsabout role identity.32

Contextual issues

Relationship between agenciesThe relationship between agencies is alwayscrucial to the success of joint working initiatives.Complex relationships between the differentagencies involved in the delivery of intermediatecare were identified by Glasby et al. as a factorthat undermined the effectiveness of services.51

That study notes a perception that theintermediate care agenda was becomingdominated by the needs of acute health care atthe expense of the aims of community services,health and social care.

Constant reorganisation and lack of coterminosityThe continual drive to reform welfare services,particularly in relation to health and social care,was another factor that undermined jointworking. For example, reform within the sectortends to add to the complexity of any newdevelopment51 or divert attention away fromoperational issues.29 A lack of coterminositybetween home care services and GP practicesundermined the ability of professionals to referolder people to a multi-agency team.29

Financial uncertainty Uncertainty about financing for joint initiativeswas a challenge. For example, a lack ofdesignated funding for intermediate care servicesallied to the short-term nature of funding wasreported by Regen et al. to undermine theimplementation of integrated services.53 Thesame study also notes that the financialpressures facing all health and social careagencies meant that some joint initiatives wereunder-funded.

Burch and Borland35 argue that the movetowards greater collaboration in relation toservices for older people requires adequateplanning, particularly in relation to ensuring thatfacilities are fit for purpose, and this of courserequires adequate funding. Finally, whileHultberg et al.2 report many positive factorsassociated with pooled budgets they point out

that they could damage the viability of partnerorganisations if the pooling led to afragmentation of service responsibilities.

Labour marketDifficulty in recruiting staff was another factorthat appeared to undermine the progress of some new joint initiatives.19 For example, Regen et al.53 note the difficulty of recruiting care workers and rehabilitation assistants to work in intermediate care services, particularly in rural areas.

Service user and carer views

Insights from service users and carers about theirexperiences and what outcomes matter to themare rarely included in evaluations of jointworking. When they are included, oftensurprisingly limited details are reported. This inpart reflects an evidence base characterised bysmall49 or unspecified sample sizes,33 and is alsopartly due to the fact that the views of serviceusers and carers are rarely analysed in a way thatpromotes understanding of their differing andpotentially competing needs.33,47–49 In somecases, it is simply down to the fact that the viewsof service users and carers were reportedseparately in research reports but not included inpeer review papers for publication and henceexcluded from this briefing.16,34,50

Where evaluations took account of service usersand carers, samples were largely drawn from thewhite population, meaning black and minorityethnic (BME) groups are under-represented. Onlyone evaluation of dementia services directlyaddressed the importance of improving referralrates from BME groups, although their views arenot reported in any detail.26 Diversity in terms ofsexual orientation is never specified, meaningthat any implications for lesbian, gay, bisexualand transgender (LGBT) people are missing fromevaluations of different types of service delivery.These limitations make it difficult to assess theimpact of integrated services on the experiencesof all service users and carers. However, whereaccessible evidence exists, integration isassociated with increased user involvement,choice and control.


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ExperiencesMany service users report high levels ofsatisfaction with integrated services.18,24,28,33,47–49

Service users value:

• responsiveness to their needs through moretimely initial assessment and subsequentinterventions18,28,33,49

• partnership working and the development oftrusting relationships with named keyworkers18,24,29,49

• improved communication between agencies15,49

• help interpreting information and navigatingunfamiliar and complex systems33

• support to maintain their independence in thecommunity.24,28,46,48,49

As one older person who had been referred tofive different health and social care servicesfollowing assessment by a multi-disciplinaryteam targeting older people at risk said, ‘I thinkit’s [the team service] excellent; it’s been alifesaver for me. It’s opened up so many vistas forme. They’ve helped enormously.’28

Like service users, carers also welcomed theresponsive nature of the service, highlightingtimely assessments and interventions that weretailored to their individual needs as well as thoseof the service user.18 They valued the additionalsupport and felt relieved of some of theirresponsibilities, which led to reduced stress andfewer crisis situations.33 This was particularlywelcome where carers were combining caringwith other responsibilities, such as parenting, or crucially where carers were service usersthemselves.49 As a carer and service usercommented when describing a new intermediatecare rapid assessment service, ‘I don’t want to gointo hospital, you know. I look after my wife … I think that the idea that the scheme preventsthis is very good.’49

Comparative studies suggest that such support is not necessarily available in standard, non-integrated services.18 Based on a study of 64 carers of people with severe mental healthproblems served by four different mental health

care services, Schneider et al. conclude that thecarers in integrated districts were ‘on the wholeless adversely affected by their role’.20

Links between service organisation and user satisfactionUnravelling the impact of service organisation onservice user and carer satisfaction can be difficult.Where studies attempted to identify a directrelationship between users’ experience of aservice and changes in organisationalarrangements, people made little distinctionbetween who organised or delivered the serviceand focused only on whether or not it wasappropriate for them.25,27,29,41 In other words,service users did not articulate a concern with the integration of health and social care as such; rather they simply appreciated the fact that they had access to the support and servicesof their choice.

As part of the suite of papers concerned withhow different models of community care impacton the experiences of 260 mental health serviceusers, Carpenter et al. found ‘a statisticallysignificant advantage in terms of users’satisfaction with integration as an approach’.24

Users in integrated districts felt more able tostate their aims for care and treatment, felt less limited in their choice of care, felt betterinformed about medication and less negativeabout their family’s involvement, and were more positive about being supported inindependent living. The authors suggest that this is linked to the following features ofintegrated services:

• ‘holistic’ common assessment protocols thatinclude social care as well as clinical mentalhealth needs

• a single key worker/care manager based in the community (a system that both serviceusers and carers welcomed as promoting more choice than hospital-based dischargeplanning)

• key workers having the authority to useresources from both agencies, without needing to refer users to an assessor in another agency.

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The authors conclude that ‘user involvement andchoice is facilitated by policies and procedures inintegrated service districts’.24

Dissatisfaction and difficultiesDespite this, service users and carers also reportedsignificant problems. Areas of dissatisfactionincluded continuing communication difficultiesbetween agencies, particularly when a service userwas to be admitted to respite care or hospital, andcontinuity of care was therefore broken. This wasespecially apparent in mental health services.49

Service users also identified difficulties with theirinvolvement in care planning and their ability toinfluence the choice of care options.33,41,46–48

Even in the best services, there is always room forimprovement. Carpenter et al.24 highlight the factthat only half of mental health service usersreported that they had a written care plan as partof the care programme approach. Feedback fromprofessionals acknowledged that the discrepancycould not be accounted for by users having lost orforgotten their care plan. Given that users weregenerally positive about their care plans, theauthors conclude that this is an area of seriousconcern and that practitioners must ‘redoubletheir efforts to ensure users receive theirentitlement to a care programme’. Peck et al.41

point out that while service users were largelysatisfied with services throughout thereorganisation process in Somerset, ‘the concernsof users about their relationship with staff – oftenexpressed in terms of staff attitudes – appears tohave played no part in the design andimplementation of the changes’.

Outcomes that matter to service users and carersThe complexities of developing appropriateoutcome measures, particularly for older people, are widely recognised.34 However,although some studies attempted to captureuser- and carer-defined outcomes, theseoutcomes were not always well described.28

Only one study provided a detailed analysis ofthe outcomes that matter to the people using theservices themselves. McLeod et al.33 conducted a

small-scale qualitative evaluation of thesignificance of the social worker services receivedby older service users on admission to accidentand emergency (A&E) departments. Thedevelopment of social work in such departmentswas part of a joint health and social care policydrive to divert older people from ‘unnecessary’admission to acute hospital care on social caregrounds. However, the authors conclude thatfrom the older people’s standpoint the primecriterion for assessing social work needs in theA&E environment was not its powers of diversion but its contribution to optimum health and social care. McLeod et al. argue that it should not be assumed that social care can be a substitute for emergency admission; from anolder people’s perspective they often consideredtheir admissions to be caused by a medicalemergency that required hospital treatment atthat time.

Gaps in the research evidenceStudies largely focus on small-scale evaluationsof local initiatives that are often of poor quality and poorly reported. Details aboutworking practices and arrangements are oftenlimited and/or the authors fail to discuss thefactors that promote and hinder joint working.Few studies are comparative in design, sodifferences between ‘usual care’ and integratedcare are not assessed. Small-scale, ‘boutiqueevaluations’ of joint working make it difficult to draw firm conclusions about the effectiveness of UK-based integrated health and social care services.

As indicated, evidence on cost-effectiveness wasnot identified in our searches. This means that wehave no means of assessing the costs andbenefits to service users and carers of integratedcare versus standard care or different types ofintegrated services.

The voice of service users and carers remainslargely absent. Their views are not routinelycollected in evaluations, which makes it almostimpossible to comment on the outcomes thatmatter to the people who use services


themselves. Where they are included, serviceusers and carers are treated as a homogeneous group. This makes it difficult tounravel the impact of integrated services ongroups who may have different and sometimescompeting needs.

The impact of personalisation on integratedservices is missing from this briefing. Most of thestudies pre-date 2007 and the signing of thePutting people first concordat in England, a jointagreement between the NHS and localauthorities which was also signed by theDepartment of Work and Pensions.13 This meansthat we cannot comment on the development ofpersonal budgets and any effect this has had onthe way in which health and social care servicesare organised. Nor can we comment on thepotential of integrating personal budgets,assessment and self-directed support planning in health and social care and what this may mean for the experiences and outcomes ofservice users and carers. For recent informationon the effectiveness of joint working, the national evaluation of DH’s integrated care pilotsprovides a detailed assessment of 16 projectsthat aimed to integrate care, largely betweencommunity-based services such as generalpractices, community nursing services and social care.58

Implications from theresearchImplications for organisations

A clear message emerging from the research isthe need to ensure that new partnerships andintegrated services are developed in such a waythat the different professions and agenciesinvolved understand their the aims andobjectives, and appreciate the relevance of theinitiative to the local context. The involvement ofoperational staff in initial discussions about suchventures is one way to overcome misconceptionsabout new services, while regular meetingsprovide an opportunity to develop policies andprocedures as well as offering a setting to resolveproblems and review practice.

Transparent and appropriate managementarrangements are vital to the success of any jointworking venture. Clearly articulated and effectivemanagerial structures, that incorporate bothprofessional as well as organisational managerialsupport, appear to be associated with stafffeeling more secure and confident in their newroles and working contexts.

Implications for practitioners

Successful joint working requires practitioners toreconcile their professional values and roles withthe aims and objectives of the joint initiative.One way to achieve this is to ensure that theoutcomes for service users and carers are madeexplicit from the start, so that practitionersappreciate the benefits of the joint activity tothose they support, and progress can bemonitored routinely.

A willingness and ability to share information in atimely and appropriate fashion is also key to jointworking. Attention has focused on establishingthe means to share information (such as shareddatabases and compatible IT systems). However,there remain some professional barriers tosharing information and attention needs to bepaid to ensuring that professionals understandthe need to do this and have confidence in theprocesses in place for doing so.

Implications for service users and carers

Defining outcomes that matter to service usersand carers is important. Outcomes defined byservice users may differ from policy and practiceimperatives and are a crucial aspect ofunderstanding the effectiveness of integratedservices from the perspectives of the people whouse them.

Integrated services work best when they promote user involvement, choice and control.Although most service users and carers reporthigh levels of satisfaction, more can be done toinvolve them in care planning and influencingfuture care options. Such involvement in thecurrent policy context is the cornerstone of self-directed support.

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Service users and carers value services that areappropriate to their needs; they are lessconcerned with how services are organised.Service users value timely assessment andservices, partnership, and the development oftrusting relationships with named carecoordinators. Improved communication andcoordination between agencies is also importantto them. Carers value assessment in their ownright and welcome additional support, particularlywhen they are service users themselves.

Implications for researchers

Given the importance of the issues raised in thisbriefing for policy-makers, there is clearly a needfor researchers to sharpen the approachesbrought to studies of joint working. The centralissue for research is to develop ways ofidentifying and evaluating the outcomes of jointworking for users and carers. Compared with theearlier review, there were more papers includedthat did this, but they tended to be clustered inthe bigger, more complex studies.

There is also a need for studies to describe moreclearly the organisational models being used.Words like ‘team’ cover a multitude of forms, andit was not always possible to discern from thepublished papers how different research sitesoperated in terms of some of the key issues suchas communication, information sharing andmanagement arrangements.

Implications for the policy community

The evidence base on joint working remainslacking. While there is some indication thatintegration in particular may have positive

benefits for organisations as well as for users andcarers, there is a need for more high-quality,large-scale evaluations to test the underpinningassumptions in a more robust manner.

Studies exploring the establishment of integratedservices/systems consistently report a lack ofappreciation of the aims of integration amonghealth professionals. Additionally, there appearsto be concern that the contribution ofcommunity health and social care services mightbe marginalised by the interests of the acutesector. Such perceptions are not helpful andsuggest that more attention needs to be paid toexplaining the aims of this policy, and itscontribution to health and wellbeing, if it is to be successful.

ConclusionThere are some tentative signs that progress hasbeen made since our original review and that it isnow possible to demonstrate some positiveoutcomes for users of services, carers and serviceorganisations. However, the evidence base ispatchy and more research is required to sharpenand broaden our understanding of theseoutcomes.

There is a need for more high-quality andcomplex studies to be undertaken in order togather sufficient data, on a large enough scale, todemonstrate the effectiveness of joint workingfor users of services and the wider health andsocial care economy. Without this evidence basesome professionals will remain sceptical aboutthe importance of joint working and integrationto adult health and social care.


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Useful linksShaping our livesA national network of service users providingresources on the design, delivery and experiencesof integrated care from the perspectives ofpeople who use services themselves. www.shapingourlives.org.uk/

DH Care NetworksThe DH Care Networks existed to improveoutcomes for service users and carers viaintegration between health and social care. The archive site provides a list of the networks,including personalisation, dementia, dignity incare and commissioning.www.dhcarenetworks.org.uk/

The national evaluation of the DH integratedcare pilots can be found at:www.dh.gov.uk/en/Publicationsandstatistics/

Health and Social Care Partnerships,Collaboration and Integration ProgrammeOffered by the University of Birmingham’s HealthServices Management Centre (HSMC) for healthand social care communities to investigate issuesof collaboration through research, consultancyand the dissemination of good practice.www.birmingham.ac.uk/schools/

NHS Future ForumThe NHS Future Forum was set up to reportpeople’s views on the Health and Social Care Bill,and integration has emerged as a key theme.www.dh.gov.uk/en/Publicationsandstatistics/

Research in practice for adults (RIPfa)A round-up of the evidence for integrated care aimed at staff in health and social care who are dealing with the integration agenda on a daily basis, provided in an accessible and up-to-date format.www.ripfa.org.uk/publications/integratedcare/

The King’s FundIntegrated care is a key theme of The King’s Fund,which provides multiple resources and forums forpolicy and practice debate.www.kingsfund.org.uk/topics/

Related SCIE resourcesAt a glance 18: Personalisation briefing –Implications for community mental health serviceswww.scie.org.uk/publications/ataglance/ataglance18.asp

At a glance 30: Personalisation briefing –Implications for NHS staffwww.scie.org.uk/publications/ataglance/ataglance30.asp

At a glance 45: Social care and clinicalcommissioning for people with long-termconditionswww.scie.org.uk/publications/ataglance/ataglance45.asp

Research briefing 33: The contribution of socialwork and social care to the reduction of healthinequalities: four case studieswww.scie.org.uk/publications/briefings/briefing33

SCIE Guide 30: Think child, think parent, thinkfamily: a guide to parental mental health and child welfarewww.scie.org.uk/publications/guides/guide30/

Inter-professional and interagency collaborationwww.scie.org.uk/publications/elearning/ipiac/index.asp

NICE/SCIE clinical guide 42: Dementia –Supporting people with dementia and their carersin health and social carewww.scie.org.uk/publications/misc/dementia/index.asp

www.scie.org.uk/publications/ataglance/ataglance18.asp



www.scie.org.uk/publications/briefings/briefing33

www.scie.org.uk/publications/elearning/ipiac/index.asp

www.scie.org.uk/publications/misc/dementia/index.asp

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About the development of this product Scoping and searchingFocused searching was carried out between September and October 2011. The scope included peer-reviewed papers reporting UK-based evaluations of different models of joint working acrossthe health and social care interface. It updates a previous systematic review by Cameron and Lart(2003) that reported on the factors that promote and hinder joint working between health andsocial care. Papers published before 2000 were excluded; papers before 2000 are reported in Cameron and Lart (2003).

Peer review and testingThe authors have research and topic expertise. The briefing was peer reviewed internally formethodology. It was peer reviewed externally by a leading academic expert, Professor Jon Glasby,Director of the Health Services Management Centre (HSMC), Birmingham University. We aregrateful for his comments.

About SCIE research briefingsSCIE research briefings provide a concise summary of recent research into a particular topic andsignpost routes to further information. They are designed to provide research evidence in anaccessible format to a varied audience, including health and social care practitioners, students,managers and policy-makers. They have been undertaken using methodology developed by SCIE.

The information on which the briefings are based is drawn from relevant electronic databases,journals and texts, and where appropriate, from alternative sources, such as inspection reports and annual reviews as identified by the authors. The briefings do not provide a definitive statementof all evidence on a particular issue. SCIE research briefing methodology was followed throughout(inclusion criteria; material not comprehensively quality assured; evidence synthesised and keymessages formulated by author): for full details, seewww.scie.org.uk/publications/briefings/methodology.asp

SCIE research briefings are designed to be used online, with links to documents and otherorganisations’ websites. To access this research briefing in full, and to find other publications, visitwww.scie.org.uk/publications/briefings/


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The implementation of individual budgetschemes in adult social care

Identification of deafblind dual sensoryimpairment in older people

Obstacles to using and providing ruralsocial care

Stress and resilience factors in parents withmental health problems and their children

Experiences of children and young peoplecaring for a parent with a mental healthproblem

Children’s and young people’s experiencesof domestic violence involving adults in aparenting role

Mental health and social work

Factors that assist early identification of children in need in integrated or inter-agency settings

Assistive technology and older people

Black and minority ethnic parents withmental health problems and their children

The relationship between dual diagnosis:substance misuse and dealing with mentalhealth issues

Co-production: an emerging evidence base for adult social care transformation

Access to social care and support for adults with autistic spectrumconditions (ASC)

The contribution of social work and social care to the reduction of healthinequalities: four case studies

Communication training for care homeworkers: outcomes for older people, staff,families and friends

Black and minority ethnic people withdementia and their access to support and services

Reablement: a cost-effective route tobetter outcomes

Mental health service transitions for young people

Mental health, employment and the social care workforce

Preventing loneliness and social isolation:interventions and outcomes

End of life care for people with dementialiving in care homes


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Factors that promote and hinder joint and integrated working