Peter Thistlethwaite Honorary Fellow, University of Exeter Editor, Journal of Integrated Care

1. Integrating Social Services and the NHS:Using action research to influence and sustain mainstream service improvements Peter Thistlethwaite Honorary Fellow, University of Exeter Editor, Journal of Integrated Care 01752 840752 peter@whg.org.uk

2. Introducing my approach

3. Content and Focus • What is meant by “integration”? • What are the benefits of integration? • Why “mainstream”? • Why action research? • A locality case study: Torbay

4. What is meant by “integration”? The clinical view – Leutz, 1999 (Five laws for integrating medical and social services: lessons from the US and UK. Milbank Quarterly, 77(1)) The organisational view – WHO, 2001 (Grone & Garcia-Barbero: Trends in Integrated Care – Reflections on Conceptual Issues. www.euro.who.int/document/ihb/Trendicreflconissue.pdf

5. Leutz’s framework Linkage understanding, communication (least needs)……to Coordination structure, care managers, simultaneous responses (moderate needs)……to Integration pooling,controlling (severe needs)

8. Grone & Garcia-Barbero (WHO) • Integration is a means to improve services in relation to access, quality, user satisfaction and efficiency • Integration is a means to an end, not an end in itself

9. What are the benefits of integration? A user-centred distillation • Improving access to services overall • Eliminating buck-passing • Simplifying decision-making processes • Increasing efficiency (cutting out duplication, etc) • Shortening time from need identification to service delivery • Reducing communication failure

10. Added benefits from integration? • New identity = new allegiances, cleaner break from the past • Efficiencies: admin & management; new roles • More focus, clearer accountability, less confusion & distraction • Improved leadership & teamwork – pulling together • New investment opportunities

11. Why “mainstream”? • Specially funded projects ought to succeed: evaluations of these are not really good evidence of potential for wider change • However good policies are, research has demonstrated that implementation is difficult, and positivism has limitations, eg Wildavsky, Lipsky: this is where evidence should be sought • Not enough people know about research; too few read

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

13. Key points from the process • It is a joint inquiry; problem-solving, testing aims & claims • Empowering; reflexive practice; learning • Researcher as catalyst, open about own values…not elitist • A cyclical process – a succession of cycles – and about change • Bridges the gap between theory, research and practice…at multiple levels • Non-positivist approach to change

14. Case Study: Locating Torbay

15. The 3 towns of Torbay: Torquay, Paignton & Brixham

18. Torbay • Population 132000 (Brixham 20000 pilot) • Torbay Borough Council – responsible for Social Services (Brixham: 6 care managers, residential & intermediate care unit, home care, OT) • Torbay NHS Primary Care Trust – responsible for community health services (Brixham: 12 GPs in 3 Practices, 20-bed community hospital, nursing and therapy staff) • South Devon Healthcare NHS Trust – responsible for Torbay Hospital (acute) • Devon Partnership Trust – mental health services

19. Care Trust –single organisation, dual accountability

20. Timescales for change processand the action research • January 2004 Agreement PCT/TBC • April 2004 Chief Executive (designate) • June 2004 Locality Manager - Brixham • Summer 2004 Baseline measures & feedback • November 2004 Care Managers for Brixham released • December 2004 Brixham Objectives set

21. Timescales (cont) • Nov 2004 3 months formal public consultation re Care Trust • March 2005 Second measures & feedback • April 2005 ? “Shadow” Care Trust starts • Summer 2005 Third measures & feedback • October 2005 Care Trust established

22. Baseline evaluation: Summer 2004 • Existing Objectives for integration • document analysis • Opinions of practitioners and front line managers semi-structured interviews • The referral pathway from NHS to social care service provision file audit & interview • Performance on this pathway • management information

23. Baseline findings • Objectives – couched in general terms, and not specific about user benefits • Staff opinions – integrated practice “not achieved” or, at best, “partly achieved” • Referral pathway NHS to SSD – bureaucratic, linear, segmented, limited feedback • Performance on this pathway - below par: referral to allocation 15 days ave (0-81) allocation to assessment 11 days ave (0-118)

24. Feedback – Autumn 2004 Greatest deficiencies: • Unspecific objectives for users (remedied in consultative document) • Lack of locally based care managers, service manager (staff designated Nov, still not co-located, and community-MDT working not established) • Linear referral process (projects to establish MDT shared database; and speed up basic processes) • Lack of engagement of home care services (fully engaged) • Uneven relationships between PCT/SSD staff and primary health care (relationships and communication improving)

25. Second round of data collection • Started March 2005 • Not quite completed • Analysis preliminary • No feedback yet

26. Objectives set in Brixham for Jan-April 2005 “Our Vision for Brixham……… To deliver seamless integrated services to the patients, users and carers of Brixham which enable them to maximise their independence in accordance with their abilities and wishes”

27. Objectives (cont) • Single point of access/immediate contact • Streamline system of m/d teamwork, inc assessment • Stratification of total caseload, key worker for most vulnerable (a la Kaiser) • Review of established meeting patterns… • …esp developing links with GPs

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

29. Staff opinions • Teamwork, improved face to face contact and communication, shared decision-making all seen positively; • Rating of progress towards integrated practice up 20% from summer 2004 • Now “satisfactory/partly achieved”, and would be “excellent/optimally achieved” with more progress on certain key areas:

30. Staff opinions: key areas holding back progress • co-location (options being explored); • community MDT working; • SAP implementation (still duplicating); • single point of access (being established); • pooling of budgets/sharing resource information; • more community carers (to facilitate hospital discharge) (major initiative)

31. Some concluding points • Experience confirms the well-known barriers…IT, co-location, cultures, political differences, independence of primary health care…but PCT leadership has anticipated these effectively • Political agreement mattered – council enfeebled by regulators’ appraisals; PCT had top star rating…saw advantage of integration for patients • Locality manager (ex SSD) has inclusive style • Positive response from practitioners -although cultural differences may yet slow progress in Paignton and Torquay • SSD management frustrated progress, wanted to slow pace of change

32. Some myths? • Integration “is not rocket science”…it is more difficult because of lack of precision, unpredictablility • Is the “postcode lottery” such a bad thing? Isn’t it inevitable to a degree? • Let’s value “reinventing the wheel”: it engages people creatively!