Fiona Catcher, Vanguard Consulting
It’s become a bit of a litmus test for me. Asked what integration meant to her, an occupational therapist told me wryly, ‘Now we get to keep our milk in the same fridge!’ Ever since, I’ve made a point of checking the fridge of integrated teams or services I’m spending time with. She’s right. More often than not I’ll see milk labelled ‘OT’, ‘Physio’, ‘Social’, ‘Nurses’ – indicative that the system continues to be constrained by professional roles and boundaries and that well-intentioned efforts to integrate result in little more than co-location in practice.
Integration of health and social care is a key priority of the government’s public-services reform agenda. It is heralded as the solution to the problems that the current unjoined-up system provides for citizens and the way to achieve greater efficiency and financial savings. Significant funding has been made available through the Better Care Fund to incentivise agencies to work together to transform care through integration approaches.
The advantages are often expressed in terms of better coordination and navigation, improved communication and information, better outcomes, more patient / person centric, more joined-up, more efficient. The list of proposed benefits is long and compelling. Given the current unsatisfactory state of affairs, who wouldn’t want these things?
The first half of this article describes what happens when you start with the question ‘How can we join up services to get better outcomes?’ In the second half of the article, we look at what happens when we ask a different question, ‘how can we do better things?’ I end by making the case for a radically new and different approach to care with profound implications for citizens, staff and budgets.
Complicated, confusing and frustrating
Everyone agrees the current health and care system is complicated and fragmented. For citizens, the journey through it can be disjointed, confusing and frustrating. It often fails to recognise real need. When demand is studied from the citizen’s perspective, 85% of those who present at a health ‘front door’ are found to have additional social or psychological needs. Yet the system is geared to respond only to the presenting (singular) need, not to understand its contextual (compound) nature.
Health services are separated from social care, adult care from children’s care, and mental health from physical health. In the cause of greater efficiency and productivity, each separate part is further functionalised and specialised – so that even professionals have difficulty navigating the system.
When it receives a demand, each department or service focuses on ‘is this for us?’, and if it is, ‘we’ll do our bit and pass it on’. Needs are identified by formal assessment. To address other needs, the citizen is referred on to another department, at which point the cycle starts all over again, amplifying system-wide duplication and waste. In one town, the 280,000 demands received by eight agencies over a year were 60,000 more than the local population.
While people are cycled around the assessment and referral system – often over years – they become less stable and more dependent on services. They continue to present to multiple ‘front doors’, fuelling the perception that demand is rising. But this is an optical illusion. Analysing demand reveals that typically 80% of demands into health and care services are failure demands (demand caused by failure to do something or to do something right for the citizen).
Criteria and thresholds are key mechanisms for rationing access to services and prioritising those in need, driven by the belief that this will control demand and protect budgets. From understanding the cost, waste, and predictable impact on people of this vicious circle, we learn that it has the opposite effect.Staff are the system’s most valuable resource. Yet when flow of work is studied, we discover that this resource is mostly used on work that is of no value to the citizen – dealing with failure demand, and the rework and duplication of assessing and referring. In other words, it is waste. In one health and care system 90% of work carried out was found to be waste, consuming 75% of staff capacity.
Integration – starting with the wrong question
In the face of these issues, integration seems a compelling answer.
But in the sense in which it is usually applied, integration simply amounts to doing today’s things better. Asking ‘how do we join things up?’ is to start with the wrong question. It does nothing to challenge the logics of the design and management of the current system. Crucially, it misses the opportunity to pose the anterior question of what’s needed and then to draw up an integrated design to make it happen.
Let’s look at the design of the integrated health and care service our occupational therapist (remember the milk?) worked in. Previously, occupational therapy, physiotherapy, community nursing and social care each had its separate teams, managers and ‘front doors’ (referral desks); performance measures, too. These teams were brought together, with an integrated referral desk, under an integrated manager. The social-care IT system was modified to allow all specialisms to record into the same system.
But from a citizen’s perspective, how much had changed?
Arguably, the single ‘front door’ was an improvement. But as soon as a referral was taken it was allocated to a separate list for each specialism, each with its own professional lead to ensure that professional standards and values weren’t lost in the new set-up. Leads would manage allocation into their profession and performance against the appropriate measures, most carried forward from the previous regime. As a consequence, priorities and perspectives continued to be largely dominated by profession. If a home visit revealed needs outside the professional remit of the visiting team member, they were referred on using the appropriate referral form. The new IT system meant that information was better co-ordinated and easier to find – but since most of the improvements were process-related, in practice the new system was no better able to understand what mattered to citizens and therefore how to solve their problems than before.
Evaluation of many integration approaches, including national pilots, confirm that most improvements are process-related. Tellingly, the assumption that they lead to better actual care is not evidently shared by those on the receiving end.
Most integrated services continue to operate as one of many ‘referral doors’ to the system, with pre-integration thresholds and criteria still in place. The cycle of referring (failure) demand from one professional to the next continues unabated. In a recently integrated primary-care team professionals daily screen referrals from 34 different sources to decide which are ‘for us’ and which can be referred back or on to someone else. Demand pressures mean that even those deemed ‘for us’ are further prioritised according to perceived urgency. The most urgent cases are referred to a rapid-response team that struggles to cope. Others are assigned to professional leads according to medical need and arbitrary response times for assessment. Integration has had no impact on levels of demand.
This is not surprising. The approach used does not seek to understand the drivers of service consumption. Many integration initiatives are aimed at those with complex conditions, judged most at risk of unplanned hospitalisation, assuming that they are the heaviest users. But the episodic and transactional relationship the system has with citizens, together with reliance on ‘system-shaped’ rather than ‘person-shaped’ data, means that others who repeatedly present to services, bouncing between GPs, social care and in and out of hospital, are simply not visible as high consumers to the system. Integration approaches, targeted at specific cohorts and / or for those who have reached specific threshold levels, design out the opportunity to help some of those who most need it.
Integration is not enough. Unless there is also a shift from managing illness and eligibility for services to problem-solving in the context of people’s lives, it will not meet the challenges facing today’s public services. Meeting this challenge means starting in a different place and doing better things, not today’s things better.
Beyond integration: starting in a different place
When citizens present to a health or care ‘front door’, they are asking for help to solve a problem or problems that have pushed their life out of balance. Understanding what’s needed to rebalance a life requires a radically different approach to care – a move away from providing services and towards problem-solving with citizens and communities.
Designing against demand means fully understanding what a citizen wants and designing a system capable of absorbing variation in demand. Designing roles to understand demand and to help citizens solve problems means dissolving boundaries between traditional professional roles, not just blurring them.What does the value work in a ‘help me to live my life’ system look like?Creating value for the citizen starts by taking the time necessary to properly understand them, their aspirations and assets in the context of their lives.
When citizen demand is understood from this perspective, a surprising truth emerges. The problems most affecting their lives and most driving their consumption of services are not directly connected to health or care. For example:
- A man suffering from diabetes and alcohol issues presented to A&E seven times over 63 days following falls. He was admitted five times, spending 44 days in hospital was assessed 32 times and had 13 lab tests. No one thought to see where he lived or asked him how he wanted to live. When a team did, they understood that his real problem was living conditions in a hostel. With help to move out and establish routines for looking after himself, he no longer needed services.
- An 86-year-old man who lived alone after the death of his wife was resigned to a future of meals-on-wheels, twice-daily care visits and regular nursing support. He was lonely. What mattered to him was to feel useful and connected with people. He was helped to do this and now supports himself and others around him in the community, without any service inputs.
Understanding and rebalancing a person can take several iterations. Often working out and solving the most urgent problem is critical to building the trust necessary for an individual to share their issues or even recognise them for the first time. Sometimes this is enough to create the space for the person to resolve their other issues. Establishing relationships and continuity means that if a person is subsequently pushed off kilter, it is easier, quicker – and cheaper – to help them get their lives back on track.
Doing the right thing
The implications for roles in this way of working are profound. Staff no longer lead with their profession – they are part of a seamless problem-solving team. Understanding is a core competency. If a problem lies outside an individual’s skill set, instead of referring the case on or reaching for a service, they pull the expertise required to solve the problem.
The demands of learning, or relearning, how to give someone ‘a right good listening to’ should not be underestimated. Repeatedly following prescribed assessment processes has effectively deskilled many staff, and they need support in regaining confidence to initiate and build good conversations. As they relearn, staff quickly discover that with good understanding and problem-solving, the need for assessment by default goes away.
Staff no longer spend most of their time doing work of no value to the citizen. Thresholds and criteria have been abandoned. Instead, working purposefully to new principles, they are liberated to help people who need it in a way in which has ironically returned them to their professional values. Most would not contemplate a return to the previous way of working. Citizens who have felt its impact are astonished by the comparison with the past.
And the overall result? Demand and cost fall.
Those working in this way typically report reductions in whole system cost per citizen of around 50% with consequential reductions in social care and GP contacts, non elective admissions to hospital, and where admission is required, reduced length of stay.
In one pilot area, the impact of redesigning services around the citizen has reduced activity costs for those citizens to the local authority and NHS by 42% and 67.8% respectively, saving an average of £15,000 per citizen per annum. Demand for public services in the area fell by 12.8%.
Applying this way of thinking to a Youth Protection Service achieved regional savings of £22.9m and halved the number of families under the care of the service from 8,000 (20,000 children) to 4,000.
The outcomes of doing better things? A re-invigorated workforce, satisfied citizens able to get on with the real job of living their lives with less or no need for services, and effective public services costing less.
Curious about how far along your service is on its integration journey? You could do worse than to start by taking a look inside the fridge.
Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.