Integrated care: service proximity is the aim, cultural change is the gain

It’s hard to be against integrated care, whether or not mandated by the NHS Long Term Plan (LTP). But replace ‘integrated’ with ‘better’ – it’s still laudable, but meaningless. The LTP encourages ‘localism’ – what’s right for South London might not be right for East Glasgow. But what’s ‘right’? A focus on children’s services or frailty pathways? No detail, no map, no evidence. 

We started our integration journey a couple of years ago. It was the national direction of travel and, moreover, seemed the right thing to do. It might also help make those savings we had to bridge. We polled the populace. No one offered a design of social care over here, mental health over there, and physical health somewhere else. Indeed, folk complained about that – a lot. They disliked retelling their stories, delayed referrals and multiple providers doing different things in different ways. “Simplify and speak to each other,” was the refrain.

So we went off to staff to enthusiastically inform them our local population agreed with the LTP, reinforced through slides on population ageing, problematic workforce recruitment and retention, and stormy economic forecasts. We had an answer: integrated care. Bringing together adult social care, adult mental health and adult physical health. Instead of three professional silos, we would have three hubs (hubs are so 2020), each of which would combine those three tribes, slickly working together in optimised person-centred ways. What’s not to love?

Sometimes managers live in their own little world. We said “new ways of working”, staff heard “doing other people’s jobs”; we said “upskilling”, the retort was “you mean deprofessionalisation”; we cried “fewer boundaries!”, and folk replied “increased demand”; we pleaded “but saving money…” and staff understood “you’re making people redundant”. 

Staff got integration and its potential benefits, but the ask was profound and they understandably saw the challenges through the lens of disintegrating services about which they were passionate. “Integration is great, but not for my team”. They knew the great specialist work they did and feared its loss – for their patients. 

Management compounded this, hitting things high-level and missing what mattered; or at least paying it inadequate attention. Where would staff park their cars? What about a school-run carefully built around a current team base? And this was before we hit the buffers of different IT and email systems, HR policies, salaries and contracts for those in health and social care – issues no one organisation could solve. We spent as much time as we could listening to staff anxieties, but they felt we still didn’t adequately hear. Manager self-pity at this being an un-resourced additional task got the response it deserved. 

All these contradictory tensions are simultaneously true. Integration can both bring together a wide range of skills, services and people, yet risk degeneration to a lowest common denominator. Novel educational and development opportunities are exciting yet might be in competition with trainees’ and senior professionals’ core professional needs. Reducing barriers must be good yet clearly could increase demand, or at least show us the currently hidden true population need.

I started an integrated care journey with two preoccupying questions: what is the optimal type of integration and how would I know if it is working? These remain preoccupations. We lack a lexicon of integration; it is fine to ‘do local’, but we need a matrix to understand how your integration compares with mine. We are developing an imperfect series of qualitative and quantitative markers of change, but their utility (for you, as well as me) remains uncertain.

But my thoughts have moved beyond that, shaped by the most unexpected integration gain. One that has shifted my medical practice more than anything else of the previous ten years. Culture. Integration ‘proximity’ is great, but that’s only a vehicle for delivering the underlying goodness. We don’t just have different skills in health and social care, we see the world differently. In my outpatient clinic last year, my medical student asked my patient “what is wrong and how long has it been a problem?” – that’s what we say to patients. The social work student also present asked the same person “what are you good at and what do you want to do?” – that’s what we say to people. Two worlds. 

The real integration gain – which I believe remains largely unrecognised (by health, at least) – is the strengths-based enablement approach that social care will teach us. In turn, I think we offer social care an evidence-based evaluative approach that is not always, I would respectfully suggest, as core to their practice. Our local journey continues. Early bruising, but we continue to learn, trying to hear more and better. What is beginning to win us all round – slowly – is the gradual recognition of the new ways of thinking that others can offer us. Come talk to us, we’d love to learn from you. 

Dr Derek Tracy is a consultant psychiatrist and clinical director of Oxleas NHS Foundation Trust. Follow him on Twitter @derektracy1 .