Integrated Care for the Vulnerable: the technical, organisational and political challenges

Health Care Social Care

Synopsis of talk by Professor Andrew Gray (Academic Services for Public Management) at University of York/Socialist Health Association seminar 15 October 2012

The talk begins with three case stories of integrated care – or the lack of it.

The first is of Bill and Annie, a couple in their 80s. He has terminal cancer but is mentally alert. She has accelerating vascular dementia for which she is prescribed drugs that are enabling her to retain some cognitive functions (she recognises her family but needs assistance in looking after herself. They have become part of the increasing numbers who are mixed economy consumers of health and social care – both by choice (he has an old occupational health membership) and by statute (both of them have incomes just sufficient to require them to pay towards the costs of their social care). Their strongly explicit wish is to end their days at home, a wish that is now managed by their children who have power of attorney. Both receive most of their health care at home thereby reducing the suffering for him and further disorientation for her. But this tends to by-pass their GP who does not feel he has the capability to coordinate the various decisions that are made for them by the various agents. The county council’s social care provision aggravates the situation. It assesses them independently; so, for each there is a spouse living at home who is deemed part of the care provision. As part of elderly social care, he receives daily home help visits from the County’s own social service team (who usually visit in pairs – to help with any lifting) and are helpful including with Annie even though she is not their client. Annie, on the other hand, comes under mental health services that have contracted out home care to a dementia specialist private company. Under the contract they visit singly, are with one notable exception young staff not trained in dementia care, pay no attention to any distress of Bill (who is not their client), but are fastidious in writing up their activities in a log left at the house which always ends with the entry “All well on leaving” even when, according to Bill, “it bloody well isn’t!” In the end the children dismiss the dementia care team and arrange for a live-in carer. After Bill dies, Anne’s condition worsens and it is clear she would benefit from a specialist care home. But Anne’s County Council social worker refuses to provide advice on which homes are and are not suitable on the grounds that Anne is now responsible for her own care decisions and she fears for her continued registration and litigation against her council if things go wrong.

Jackie is a single mum, overweight smoker, who has two kids by different fathers, and is pregnant with a third. She has some learning disabilities identified only after she suffers repeat criminal victimisation. She takes pride in overcoming these difficulties to provide for her children. Her oldest child, a boy, is due to move to secondary school. But she cannot manage to complete and return the forms. So the local authority (without consulting her) allocates him to his most local school where Jackie realises he will be with a group of boys he has been bullied by in primary school. Jackie has a mental breakdown.

Somewhat more successful as integrated care – because of extraordinary commitment by practitioners acting well beyond their roles – is the case of Terry. He has spent a life in and out of prison. In his late 50s he receives a short-term prison sentence for theft. The prison’s reception identifies him as alcoholic, homeless, without family, and severely visually impaired by a stroke some months before. After he spent a long time in hospital while his discharge team tried to find him accommodation, he discharged himself, homeless. The prison reception also discover that he has stopped taken his medication – as he has no GP to prescribe for him. The prison health team sorts out his physical health and gets his vision problems checked and addressed by optician. Before his release, they also contact housing bodies and manage, eventually, to find a suitable place, register him with a GP and book him into an alcohol management programme. And, as a final service, they organise and pay for a taxi to take him to his accommodation – a response to their concern for his visual difficulties and the temptations of licensed premises.

These three stories suggest something of the realities of trying to forge integrated care.

They reveal a tendency for care to be regarded as

(a) exclusive professional domains in which practitioners realise vocations and make livings,
(b) organisational possessions by which they realise individual and collective missions, and
(c) revenue streams to be protected and enhanced.

This exclusiveness of care is less the result of malign personal forces – usually the individual carers are committed and well disciplined – than of systemic factors that provide formidable challenges to integrated care.

These challenges may be identified as technical, organisational, and political.

The technical challenges include:

  •  Clarifying more explicitly what integrated care means conceptually and operationally;
  •  Determining standards for integrated care;
  •  Developing core disciplines as the fundamentals for effective integrated care.

The organisational challenges include:

  •  Structural inhibitors, e.g. horizontally segregated care organisations and vertically segregated professions, the service focused NHS and place focused local government;
  • Financial inhibitors such as the NHS payment by results (which is payment by exclusive not integrated outcomes) and target regimes linked to revenue;
  • Cultural inhibitors, e.g. the predispositions by practitioners to regard care as episodic rather than systemic.

The political challenges include:

  •  Mobilising commitment to the promotion and defence of values in integrating care as a vocation;
  • Providing legitimate mechanisms for resolving contradictions between values that will inevitably arise in complex collective endeavour;
  •  Limit political epitaph building by politicians and managers, often for career promotion.

The talk suggests a way to address these challenges through a triangulated approach to integrated care that:
1. Addresses the service user in her or his physical and social context, recognises that this context has forces of support and hindrance to effective integration, and avoids treating people as ‘conditions’.
2. Manages the service pathway in its context, identifying its distinct stages involved and the agent contributions and resources that each stage requires.
3. Develops the governance of care as integrated systems rather than discrete provisions. (By governance Andrew means the arrangements by which authority and function are allocated, rights and obligations established and regulated, and through which policies are formulated and implemented.) For integrated governance the arrangements need to identify and manage risk, not simply pass it on, and recognise that care boundaries are intrinsic to care especially for the vulnerable whose situation is often aggravated by multiple conditions and by fragmented agencies of care that these days increasingly include those from the private and third sectors each with potentially different rationalities – for good or ill – from traditional public sector providers.