An evidence base for the delivery of adult

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An evidence base for the delivery of adult services Alison Petch SSRG Event 27. 2. 12 1

Definition, definition • Integration, joint working, merger, collaboration, partnership working… • ‘methodological anarchy and definitional chaos’ (Ling, 2002) • ‘a terminological quagmire’ (Leathard, 2003) 2

The partnership continuum Relative autonomy Co-ordination Joint appointments Enhanced partnership Structural integration

Help and hinder [NHSConfed/ADASS] • Friendly relationships • Good leadership • Commitment form the top • Joint strategy and vision • Co-terminosity • Performance regimes • Financial pressures • Organisational complexity • Changing leadership • Financial complexity • Culture 5

Clarify, clarify • Integrated organisations, integrated care • Macro, mezzo, micro – – – between service sectors between professions between settings between organisation types between types of care individuals organisations structural • Horizontal and vertical integration 6

Not proven? • Process v outcomes • Brown et al (2003): ‘no findings which suggest that the integrated primary-carebased health and social care teams are more clinically effective than the traditional non-integrated method of service delivery’ • Similar – Kharicha et al, 2004; Townsley et al, 2004; Davey et al, 2005 7

International evidence • On. Lok (PACE) – USA; SIPA – Quebec; PRISMA – Canada; CARMEN - Europe; PROCARE Europe; Vittorio Veneto; Rovereto (Italy) • Integrated working reduced the cumulative number of days older people stayed in institutional care • Common features: case management; specialist assessment and a multi-disciplinary team; single point of entry; financial levers 8

In a nutshell • ‘what sort of partnerships can produce what kinds of outcomes for which groups of people who use services, when and how’ Dickinson, 2006 9

“it works in Northern Ireland” • ‘Hegemony of health’ • Priority to health agendas and targets • Limited focus of the integrated approach • The full potential of integration has not been realised Heenan (2006, 2009)

The limits of structural change • Structural change by itself rarely achieves stated objectives • Emphasis should be on service integration not organisational integration • Mergers are potentially very disruptive for managers, staff and service users, and can give a false impression of change • Mergers can stall positive service development for at least 18 months • Mergers typically do not save money

Early adopters: Knowsley, NE Lincs, Torbay, Somerset • Influence of local history and context • ‘Outcomes for Mrs Smith’ • Role of leadership at the top • Importance of integrated health and social care teams • Need for evaluation

Fried or scrambled? 13

Financial evidence • Weatherly (2010): ‘tentative evidence that financial integration can be beneficial. However robust evidence for improved health outcomes or cost savings is lacking’ • Turning Point (2010): ‘integration in health and well-being services can be cost effective. However, the evidence base is still relatively small…’ 14

In a nutshell Integration based on outcomes not targets Integration based on cultures not structures Integration based on place not organisation Integration based on delegation not transfer of functions • Integration based on clinical and professional engagement • • NHS Confederation (2010) 15

Key dimensions Vision Integrated teams Leadership Outcomes Time Culture Place 16

Personal outcomes approach ‘Outcomes for Mr Mc. Kay’ • Quality of life eg staying well, seeing people, safe, things to do • Process eg choice, listened to, reliable, responsive • Change eg improved mobility, reduced symptoms 17

Time • ‘change did not occur overnight; time was needed formal partnership agreements to be translated into changes in attitudes, culture and ways of working amongst frontline staff’ Hultberg et al, 2005 18

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