Editorial

Citation

Miller, R., Glasby, J. and White, S. (2015), "Editorial", Journal of Integrated Care, Vol. 23 No. 3. https://doi.org/10.1108/JICA-04-2015-0017

Editorial

Article Type: Editorial From: Journal of Integrated Care, Volume 23, Issue 3.

Fundamentally, it is important to understand whether integrated care is to be considered an intervention that, by implication, ought to be cost-effective and support financial sustainability, or whether it is to be interpreted and evaluated as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are being delivered and that involve multiple changes at multiple levels (Nolte and Pitchford, 2014).

In 2014 the World Health Organisation reviewed evidence of the economic impacts of integrated care. The review identifies that there is evidence of the cost-effectiveness of some integrated care approaches, but the evidence base is often of low quality and based on inconsistent and incomplete measure of outcomes. The quote above responds to this, but speaks to much more than the economic aspirations for integration. It highlights an important difference in the way in which integration is conceived – is it a “thing”, or a number of “things”, in the form of service models which can be introduced into different health and social care systems with reasonable consistency of outcomes and impact, or is it a “process”, in which health and social care professionals, managers and commissioners work together with people who access services and their local communities to improve outcomes, cost-effectiveness and inequalities. The former view sees integration as a “noun”, as an entity that can be quantified, measured, refined and deployed, whereas the latter views it is as “verb”, a means of facilitating and guiding the dialogue, discussion and debate between people, teams and organisations that results in dynamic cycles of testing and improvement.

The importance of unearthing and responding different world views in relation to integration is a common theme through this edition of the Journal of Integrated Care. Lars Edgren and Keith Barnard use the metaphor of weather forecasting to represent the complexity of working across different parts of the health and social care system, and the various and often unpredictable challenges that will be encountered. He argues that the development of “collaborative mindsets” by professionals enables fruitful relationships to emerge with patients/service users and that these relationships provide a foundation for creative and person-centred responses. Jill Manthorpe and Steve Iliffe consider the use of language, and how a single concept (“frailty”) can have alternative interpretations which suggest and indeed lead to alternative understandings and responses. Language and the mental models that underpins narratives of other agencies is the central concern of Laura Griffith’s and Jon Glasby’s reflection on a workshop which brought together senior leaders from acute hospitals, community health and social care. She notes that despite “significant admiration and possible some excessive politeness – exercises like this still reveal differences in approach, in experiences of joint working and in terms of people’s underlying world view”. Using a different methodology, Kevin Hutchinson’s research also gathers perspectives from across the Scottish health and social care system. His focus is the significant change management that would be required to introduce the new joint working legislation. He highlights three areas that require particular focus – terms and conditions of existing staff, engagement of clinical and professional leads and synthesis of joint outcomes in locality planning – and the key role of leaders in successfully responding to these new opportunities. Finally, Jenny Billings and Esther de Weger provide a comprehensive review of four contracting models that are being promoted in England (and indeed internationally) as enablers of integrated care. Mirroring the words of Nolte and Pitchford (2014) above they conclude that “while some authors are hopeful and can point to positive evaluation of similar schemes, there is significant critical commentary that they may not work and some soft evidence that they do not”. This leads to a recommendation that “there needs to be a clearer connection between the ‘real’ and the ‘imaginary’ when it comes to what the contracting models can achieve”.

But does this help us to clarify if “integration” is a noun or a verb? It would be very satisfying as an editorial team to now be able to present a definitive conclusion to this debate based on the considerable insights provided by these articles. There is certainly support for the “verb” perspective in the form of the benefits of expressing and discussing different world views, the uncertainty and unpredictability of the task, and the vital role that inspirational and engagement leadership can play in helping a shared narrative and commitment to emerge. However, there is also support for the “nouns” of integration – that contracting models will affect the way in which organisations behave, that legislation can chaperone in a new strategic relationship and that a particular mindset can facilitate more person-centred collaboration. Perhaps then it is not a question of “either-or” but “both-and” – and after all, to succeed a sentence needs both “noun” and “verb”.

Robin Miller, Jon Glasby and Sue White

Reference

Nolte, E. and Pitchforth, E. (2014) “What is the evidence on the economic impacts of integrated care?”, available at: www.euro.who.int/__data/assets/pdf_file/0019/251434/What-is-the-evidence-on-the-economic-impacts-of-integrated-care.pdf?ua=1 (accessed 19 April 2015).