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‘Integrated care’ has been a key policy priority in English health and social care in recent years – although the extent to which this commitment is real rather than rhetorical remains open to debate. While everyone working in health and social care knows that single agency responses are insufficient when trying to support people with complex needs, there is a danger that ‘integrated care’ becomes a buzzword, apparently capable of resolving a range of different longstanding policy problems at once. This is particularly the case in a very challenging financial climate, when some policy makers appear to assume that this way of working will be able to dramatically improve outcomes whilst also significantly reducing costs. Such is the faith in integrated care, indeed, that it has even spawned its own policy joke: if you rang up some policy makers in the middle of the night to say that your house was on fire (so the joke goes), they would say: “that’s a shame – what you need is more integrated care!”
Despite all this, some of the initiatives being developed to promote more integrated care seem remarkably similar to those pursued by the New Labour government of 1997–2010 – whether this is pooled health and social care funds, joint health and social care governance arrangements, integrated teams, or local pilots to produce rapid policy learning. However, one of the key lessons throughout this period is that local services seeking to integrate care can find it very difficult to do so in a system not designed with integration in mind. While different areas of the country have made progress at different times and in different ways, longstanding barriers to joint working, a rapidly changing policy context, significant central control and the emergence of other single agency priorities over time have all made it difficult to join services up in practice.
Against this background, both research and recent practical experience suggest one thing that probably will not work, and four things that might. Often, debates about integrating care can focus on integrating separate organisations, and the English NHS in particular is reorganised on a regular basis. While such structural ‘solutions’ look dramatic and bold, the evidence around mergers and acquisitions (in both public and private sectors) is that they rarely achieve stated objectives, often fail to save money and tend to reduce morale, productivity and positive service developments (often for some 18 months to two years after the initial change – if it is managed well). Moreover, the evidence from the NHS is that hospital mergers tend not to take place for the reasons stated in the consultation document – but in response to local/national politics, to save money (even though they tend not to) and to get rid of management teams that are deemed to be failing. None of this is to say that changing structures cannot be part of a broader solution; it is just that it often isn’t – and it certainly should not be the first place to start.
More fruitful might be some or all of the following four approaches:
Above all, integration should be a means to an end of better services and better outcomes for people’s lives. If it somehow becomes an end in itself then we have lost sight of something important, and integration has become part of the problem rather than part of the solution.
This perspectives paper forms part of an IJIC Special Issue on the Building Blocks of Integrated Care. The paper was drawn from a presentation made during a series of six webinars, and a public lecture, organised by the International Foundation for Integrated Care and funded by Edgehill University. Further resources, including videos and presentations, can be found at www.integratedcarefoundation.org/events/webinar-series-the-building-blocks-of-integrated-care.
The author declares that they have no competing interests.
Jon Glasby is Professor of Health and Social Care and Head of the School of Social Policy at the University of Birmingham. This commentary is based on a public lecture given as part of Edge Hill University’s ‘I4P’ lecture series in April 2016, in conjunction with the International Federation of Integrated Care. It draws on Glasby and Dickinson’s (2014) Partnership working in health and social care: what is integrated care and how can we deliver it (2nd ed.). Bristol, The Policy Press.