Integrating Social Services Integrating Social Services and the NHS:and the NHS:

Using action research to influence Using action research to influence and sustain mainstream and sustain mainstream

service improvementsservice improvements

Peter ThistlethwaitePeter Thistlethwaite

Honorary Fellow, University of Exeter Honorary Fellow, University of Exeter

Editor, Journal of Integrated CareEditor, Journal of Integrated Care

01752 840752 peter@whg.org.uk01752 840752 peter@whg.org.uk

Introducing my approachIntroducing my approach

Content and FocusContent and Focus

1.1. What is meant by “integration”?What is meant by “integration”?

2.2. What are the benefits of integration?What are the benefits of integration?

3.3. Why “mainstream”?Why “mainstream”?

4.4. Why action research?Why action research?

5.5. A locality case study: TorbayA locality case study: Torbay

What is meant by “integration”?What is meant by “integration”?

The clinical view – Leutz, 1999 The clinical view – Leutz, 1999 (Five laws for integrating medical and social services: lessons from the (Five laws for integrating medical and social services: lessons from the

US and UK. US and UK. Milbank Quarterly, 77(1))Milbank Quarterly, 77(1))

The organisational view – WHO, 2001The organisational view – WHO, 2001(Grone & Garcia-Barbero: Trends in Integrated Care – Reflections on (Grone & Garcia-Barbero: Trends in Integrated Care – Reflections on

Conceptual Issues. Conceptual Issues. www.euro.who.int/document/ihb/Trendicreflconissue.pdfwww.euro.who.int/document/ihb/Trendicreflconissue.pdf

Leutz’s frameworkLeutz’s framework

Linkageunderstanding, communication(least needs)……to

Coordination structure, care managers, simultaneous

responses(moderate needs)……to

Integrationpooling, controlling(severe needs)

(WHO)(WHO) Autonomy Coordination Integration

Vision of system

Individual perception

Shared commitment to improve system

Common values, all accountable

Nature of partnership

Own rules, occasional partnership

Time limited cooperative projects

Formal mission statements,legislation

Use of resources

To meet self determined objectives

To meet complementary objectives, mutual reinforcement

Used according to common framework

Decision making

Independent Consultative Authority delegated, single process

Information Used independently

Circulates among partners

Orients partners work towards agreed needs

Grone & Garcia-Barbero (WHO)Grone & Garcia-Barbero (WHO)

Integration is a means to improve services Integration is a means to improve services in relation to access, quality, user in relation to access, quality, user satisfaction and efficiencysatisfaction and efficiency

Integration is a means to an end, not an Integration is a means to an end, not an end in itselfend in itself

What are the benefits of integration? What are the benefits of integration? A user-centred distillationA user-centred distillation

Improving access to services overallImproving access to services overall

Eliminating buck-passing Eliminating buck-passing

Simplifying decision-making processesSimplifying decision-making processes

Increasing efficiency (cutting out Increasing efficiency (cutting out duplication, etc)duplication, etc)

Shortening time from need identification to Shortening time from need identification to service deliveryservice delivery

Reducing communication failureReducing communication failure

Added benefits from integration?Added benefits from integration?

New identity = new allegiances, cleaner New identity = new allegiances, cleaner break from the pastbreak from the pastEfficiencies: admin & management; new Efficiencies: admin & management; new roles roles More focus, clearer accountability, less More focus, clearer accountability, less confusion & distractionconfusion & distractionImproved leadership & teamwork – pulling Improved leadership & teamwork – pulling togethertogetherNew investment opportunities New investment opportunities

Why “mainstream”?Why “mainstream”?

Specially funded projects ought to succeed: Specially funded projects ought to succeed: evaluations of these are not really good evaluations of these are not really good evidence of potential for wider change evidence of potential for wider change

However good policies are, research has However good policies are, research has demonstrated that implementation is difficult, demonstrated that implementation is difficult, and positivism has limitations, eg Wildavsky, and positivism has limitations, eg Wildavsky, Lipsky: this is where evidence should be Lipsky: this is where evidence should be soughtsought

Not enough people know about research; too Not enough people know about research; too few readfew read

Why action research? Why action research?

Feedback from monitoring and evaluation Feedback from monitoring and evaluation is known to assist the change processis known to assist the change processIn In action researchaction research the researcher is a the researcher is a participant in the process of change, not an participant in the process of change, not an inscrutable observer…inscrutable observer……….and the research focus and method is .and the research focus and method is influenced by the process of changeinfluenced by the process of changeShould be practical for evidence-based Should be practical for evidence-based development; addresses complexitydevelopment; addresses complexity

Key points from the processKey points from the process

It is a joint inquiry; problem-solving, testing It is a joint inquiry; problem-solving, testing aims & claimsaims & claimsEmpowering; reflexive practice; learningEmpowering; reflexive practice; learningResearcher as catalyst, open about own Researcher as catalyst, open about own values…not elitist values…not elitist A cyclical process – a succession of cycles – A cyclical process – a succession of cycles – and about changeand about changeBridges the gap between theory, research and Bridges the gap between theory, research and practice…at multiple levelspractice…at multiple levelsNon-positivist approach to changeNon-positivist approach to change

Case Study: Locating TorbayCase Study: Locating Torbay

The 3 towns of Torbay: Torquay, Paignton & Brixham

TorbayTorbayPopulation 132000 (Brixham 20000 Population 132000 (Brixham 20000 pilotpilot))Torbay Borough Council – responsible for Torbay Borough Council – responsible for Social Services Social Services (Brixham: 6 care managers, residential & (Brixham: 6 care managers, residential & intermediate care unit, home care, OT)intermediate care unit, home care, OT)

Torbay NHS Primary Care Trust – Torbay NHS Primary Care Trust – responsible for community health services responsible for community health services (Brixham: 12 GPs in 3 Practices, 20-bed community hospital, nursing (Brixham: 12 GPs in 3 Practices, 20-bed community hospital, nursing and therapy staff)and therapy staff)

South Devon Healthcare NHS Trust – South Devon Healthcare NHS Trust – responsible for Torbay Hospital (acute)responsible for Torbay Hospital (acute)Devon Partnership Trust – mental health Devon Partnership Trust – mental health services services

Care Trust –single organisation, dual accountability

Timescales for change processTimescales for change processand the action researchand the action research

January 2004January 2004 Agreement PCT/TBCAgreement PCT/TBCApril 2004April 2004 Chief Executive Chief Executive

(designate)(designate)June 2004June 2004 Locality Manager - Locality Manager -

BrixhamBrixhamSummer 2004 Summer 2004 Baseline measures & Baseline measures &

feedbackfeedbackNovember 2004November 2004 Care Managers for Care Managers for

Brixham releasedBrixham releasedDecember 2004December 2004 Brixham Objectives setBrixham Objectives set

Timescales (cont)Timescales (cont)

Nov 2004Nov 2004 3 months formal public3 months formal publicconsultation re Care Trust consultation re Care Trust

March 2005March 2005 Second measures & Second measures & feedbackfeedback

April 2005April 2005 ? “Shadow” Care Trust? “Shadow” Care Trust

startsstarts

Summer 2005Summer 2005 Third measures & Third measures & feedbackfeedback

October 2005October 2005 Care Trust established Care Trust established

Baseline evaluation: Summer 2004Baseline evaluation: Summer 2004

•Existing Objectives for integration Existing Objectives for integration document analysisdocument analysis

•Opinions of practitioners and front line managers Opinions of practitioners and front line managers semi-structured interviewssemi-structured interviews

•The referral pathway from NHS to social care The referral pathway from NHS to social care service provision service provision file audit & interviewfile audit & interview

•Performance on this pathwayPerformance on this pathwaymanagement informationmanagement information

Baseline findingsBaseline findings

ObjectivesObjectives – couched in general terms, and not – couched in general terms, and not specific about user benefitsspecific about user benefits

Staff opinionsStaff opinions – integrated practice “not – integrated practice “not achieved” or, at best, “partly achieved”achieved” or, at best, “partly achieved”

Referral pathway NHS to SSDReferral pathway NHS to SSD – bureaucratic, – bureaucratic, linear, segmented, limited feedbacklinear, segmented, limited feedback

Performance on this pathway Performance on this pathway -- below par: below par:

referral to allocation 15 days ave (0-81)referral to allocation 15 days ave (0-81)

allocation to assessment 11 days ave (0-118) allocation to assessment 11 days ave (0-118)

Feedback – Autumn 2004Feedback – Autumn 2004

Greatest deficiencies:Greatest deficiencies:Unspecific objectives for users Unspecific objectives for users (remedied in (remedied in consultative document)consultative document)Lack of locally based care managers, service manager Lack of locally based care managers, service manager (staff designated Nov, still not co-located, and (staff designated Nov, still not co-located, and community-MDT working not established)community-MDT working not established)Linear referral processLinear referral process (projects to establish MDT (projects to establish MDT shared database; and speed up basic processes)shared database; and speed up basic processes)Lack of engagement of home care services Lack of engagement of home care services (fully (fully engaged)engaged)Uneven relationships between PCT/SSD staff and Uneven relationships between PCT/SSD staff and primary health care primary health care (relationships and communication (relationships and communication improving)improving)

Second round of data collection Second round of data collection

Started March 2005Started March 2005

Not quite completedNot quite completed

Analysis preliminaryAnalysis preliminary

No feedback yetNo feedback yet

Objectives set in Brixham Objectives set in Brixham for Jan-April 2005for Jan-April 2005

““Our Vision for Brixham………Our Vision for Brixham………

To deliver seamless integrated services to To deliver seamless integrated services to the patients, users and carers of Brixham the patients, users and carers of Brixham which enable them to maximise their which enable them to maximise their independence in accordance with their independence in accordance with their abilities and wishes”abilities and wishes”

Objectives (cont)Objectives (cont)

Single point of access/immediate contact Single point of access/immediate contact

Streamline system of m/d teamwork, inc Streamline system of m/d teamwork, inc assessment assessment

Stratification of total caseload, key worker for Stratification of total caseload, key worker for most vulnerable (a la Kaiser) most vulnerable (a la Kaiser)

Review of established meeting patterns…Review of established meeting patterns…

……esp developing links with GPs esp developing links with GPs

NHS/SSD referral pathway NHS/SSD referral pathway (average and range)(average and range)

Referral to Referral to allocationallocation

Referral to Referral to assess-assess-mentment

Assess-Assess-ment to ment to servicesservices

Baseline Baseline summer summer 0404

15 days15 days

(0-81)(0-81)

27 days 27 days

(0-146)(0-146)

5 days 5 days

(0-45)(0-45)

Round 2Round 2

Torquay & Torquay & PaigntonPaignton

5.5 days5.5 days

(0-20)(0-20)

10 days 10 days

(0-27)(0-27)

4.5 days 4.5 days

(0-57)(0-57)

Round 2Round 2

BrixhamBrixham

4 4 (2) (2) daysdays

(0-14)(0-14)

10 10 ((7)7)daysdays

(0-32)(0-32)

3 3 (5) (5) daysdays

(0-22)(0-22)

Staff opinionsStaff opinionsTeamwork, improved face to face contact and Teamwork, improved face to face contact and communication, shared decision-making all communication, shared decision-making all seen positively;seen positively;

Rating of progress towards integrated Rating of progress towards integrated practice up 20% from summer 2004 practice up 20% from summer 2004

Now “satisfactory/partly achieved”, and would Now “satisfactory/partly achieved”, and would be “excellent/optimally achieved” with more be “excellent/optimally achieved” with more progress on certain key areas: progress on certain key areas:

Staff opinions: key areas holding Staff opinions: key areas holding back progressback progress

co-location co-location (options being explored)(options being explored); ;

community MDT working; community MDT working;

SAP implementation (still duplicating); SAP implementation (still duplicating);

single point of access single point of access (being established)(being established); ;

pooling of budgets/sharing resource pooling of budgets/sharing resource information; information;

more community carers (to facilitate hospital more community carers (to facilitate hospital discharge) discharge) (major initiative)(major initiative)

Some concluding pointsSome concluding points

Experience confirms the well-known barriers…IT, Experience confirms the well-known barriers…IT, co-location, cultures, political differences, co-location, cultures, political differences, independence of primary health care…but PCT independence of primary health care…but PCT leadership has anticipated these effectivelyleadership has anticipated these effectivelyPolitical agreement mattered – council enfeebled Political agreement mattered – council enfeebled by regulators’ appraisals; PCT had top star rating…by regulators’ appraisals; PCT had top star rating…saw advantage of integration for patientssaw advantage of integration for patientsLocality manager (ex SSD) has inclusive styleLocality manager (ex SSD) has inclusive stylePositive response from practitioners -although Positive response from practitioners -although cultural differences may yet slow progress in cultural differences may yet slow progress in Paignton and TorquayPaignton and TorquaySSD management frustrated progress, wanted to SSD management frustrated progress, wanted to slow pace of changeslow pace of change

Some myths?Some myths?

Integration “is not rocket science”…it is Integration “is not rocket science”…it is more difficult because of lack of precision, more difficult because of lack of precision, unpredictablilityunpredictablility

Is the “postcode lottery” such a bad thing? Is the “postcode lottery” such a bad thing? Isn’t it inevitable to a degree?Isn’t it inevitable to a degree?

Let’s value “reinventing the wheel”: it Let’s value “reinventing the wheel”: it engages people creatively! engages people creatively!