Abstract
Background: The population in England is growing, with an anticipated extra four million people by 2034, and it is aging, with an increasing percentage aged over 65. It is also becoming more clinically complex, with greater numbers of people having more than one health condition and needing greater input from health and social care. In parallel, the workforce in these industries has not been keeping pace with need, and there is a widely agreed workforce recruitment and retention crisis, exacerbated by the covid19 pandemic. Current vacancy rates run close to 10 percent before even considering any future expansion. Funding of health and social care also appears unlikely to meet this growing need, and social care has a particular requirement for profound reform of its model.There is consensus that the status quo is unsustainable, and indeed not appropriate. There is a need to do things differently. A more complex cohort needs a different care model that can strategically adopt a preventative approach to developing conditions, whilst simultaneously managing greater co- morbidities and longer-term illness management.
In response to this, health and social care policy in England has been undergoing its greatest change in a generation. Against an erstwhile model of competition to putatively bring down costs, the shift over the past decade has been to a collaborative model of ever greater integration of services. This has been at all levels, from primary care, through secondary care, to tertiary and specialist, and between health care and social care. Following the 2019 NHS Long Term Plan, this was codified in law by the 2022 Health and Care Act that mandated the establishment of Integrated Care Systems (ICSs) and Integrated Care Boards (ICBs). These bring together relevant organisations in geographically meaningful ‘population footprints’ of one to two million people. They are intended by design to be modifiable to local needs.
However, two distinct gaps emerge from this. The first is the lack of a relevant analysis of policy documents, both legislative and strategic, and how these have impacted the actual integration of mental health and medical and social care services in England from the 2012 Health and Social Care Act onwards. There is no critical analysis of the aims, scope, processes, and intended impacts of existing policies. The second is a lack of research aimed at understanding how healthcare providers have experienced these changes, including facilitators and inhibitors of integration.
Aims and objectives: the aim of this dissertation is to generate new understandings of the implementation of ICSs in practice. The objectives are: 1. to identify relevant policy and legislative documents impacting mental health services in England with analysis of their aims, scope, processes, and intended impact; 2. to analyse early response to these policy changes, looking at different staff levels to understand their perceived appropriateness in principle and effectiveness in implementation; 3. to identify factors that facilitate and inhibit implementation of more integrated care systems in England from the perspective of healthcare staff.
Methods: Firstly, following attaining external expert opinion outside of the dissertation group, for the review and analysis the model of Alderwick et al was chosen: this model reflects how a review of policy and legislation is not the same as a review of the impact of such interventions. Further, what is deemed crucial is setting out the boundaries of the enquiry so that it can be scrutinised by others for completeness. Following this, relevant key policy and legislation documents impacting integration in mental health services in England were identified, agreed, and included.
The criteria applied in selecting relevant documents were: include overarching health and/or social care objectives. Background or enabling legislation, and geographically specific devolution, race or other equality, and mental health act legislative works were excluded. For each, data were considered in terms of impacted populations, partner organisations, summary of document, intended aims, and actual outcomes. These were used in the textual description of the included works, and thereafter in summarising lessons learned from these.
Secondly, using Rogers’ Diffusion of Innovation framework, qualitative analysis of provider staff perceptions was undertaken at three levels: a micro frontline (N=14), a meso NHS Trust Board (N=14), and a macro Integrated Care Board (N=5).
Results: Legislation and policy have well-captured the need for change and putative gains of more integrated systems However, they are largely optimistic in their objectives and tone, and have generally failed to anticipate or describe problems in practice with these changes or the concerns of staff who deliver them.
Participants at all levels saw the inefficiencies of current models and were keen for more integrated care. However, their motivations and drivers were often quite different to those of policy. Data from participants support many of the putative gains, as well as some emerging problems of new integrating systems. However, these were not being well captured by existing systems. Participants suggested mechanisms for measuring change in integrating systems, but with no central guidance on this, little evaluation was occurring in practice, hindering implementation, and limiting learning.
Early experiences of integration have generally been poor with regards to information technology and other purported back-office efficiency gains. Indeed, the opposite has commonly been true, with greater duplication and double running of systems. Staff identity, effective leadership, and culture were considered by participants to be essential to effective implementation of integrated care. However, these factors were felt to be either forgotten or ignored by policy and ICSs, compounded by an overall lack of a communication and learning strategy. This again limits the effective diffusion of better integrated healthcare.
The cultural and practice gains from better integrating health with social care have largely not been recognised or understood. At a frontline level, there is evidence for quite profound and positive gain in practice for both health and social care from their often distinct yet complementary approaches. At a macro level, actual integration between health and social care remains enormously problematic.
Conclusion: The population, workforce, and financial drivers are unambiguous on the need for more integrated care. Legislation and policy have tracked this with mandated moves to Integrated Care Systems, but largely ignored potential challenges, including staff concerns, or ways to measure and learn from these large system changes. Qualitative data show that staff at all levels support the drivers for change. However, failure to capture the issues that matter to them, the emerging anecdotal gains and problems, and to grasp the profound cultural and practical opportunities and challenges of integration with social care, are hindering effective diffusion of this necessary innovation.
Limitations of this dissertation include the narrative approach to the policy review, and the author’s working at senior levels within the systems evaluated.
Implications from the dissertation include the need to establish better measurement and comparison across integrated care systems, recognising the many confounders in their inherent population and structural differences. Human factors of relationships, leaders and leadership, and team and organisational culture might meaningfully be explored and worked upon to identify challenges and to optimise change. There is a need for better communication of learning at all levels, from within changing teams, to ICBs and national dissemination.
Future research might explore the perceptions of patients and carers, staff in primary care, acute NHS Trusts, and social care.
| Date of Award | 1 Dec 2024 |
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| Original language | English |
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| Supervisor | Sukhi Shergill (Supervisor) & Kara Hanson (Supervisor) |