As the UK struggles to integrate and personalise services, academics Jon Glasby and Helen Dickinson ask whetherthere are answers to be found overseas
When former health secretary Frank Dobson described the relationship between health and social care in terms of a Berlin Wall, he did two things. First, and deliberately, he conjured up a powerful image of a large and imposing structure, artificially dividing two territories that ought naturally to be one. For many, this captured the essence of the key issues – and the image was repeated by policy commentators. Second, and perhaps unwittingly, his use of a European analogy raised an inevitable question about the extent to which this was solely a national issue.
In a busy workplace and with rapidly evolving policies, it is easy to think that your own experiences of interagency working are the result of local or sometimes national policies and structures. However, even a quick review of the international evidence suggests that this is not the case. Although it might not always seem directly relevant to the day-to-day realities of frontline practice, learning more about overseas experience help to illuminate and reinforce key issues closer to home.
When a new concept and a new way of working becomes prominent in most, if not all, developed countries at the same time, then something fundamental is happening. In recent years, partnership working and interagency collaboration are an important and growing phenomenon. No matter how each system funds, organises and provides its welfare services, significant gaps and barriers exist, and greater co-ordination and collaboration remain a key aspiration. While the terminology used, the structures adopted and the chronology of policy change may vary, the underlying desire to create services that operate more effectively with each other is equally strong.
Several key themes emerge when reviewing this international experience.
Similarity in approaches
Although different countries have different histories and contexts, there are surprising similarities in terms of the approaches that seem most promising. In North American models of integration, for example, key success factors appear to include:
● The use of umbrella organisational structures to guide integration.
● The role of case-managed, multidisciplinary team care in meeting client needs.
● The value of organised provider networks in delivering care.
● The use of financial incentives to promote prevention, rehabilitation and downward substitution of services.
The experiences of reforms in many countries suggest that issues of interprofessional practice, culture and organisational development may be more important than the specific structures adopted.
Equally helpful are some of the emerging lessons about what doesn’t work. For example, the international evidence seems clear that integration costs before it pays, so those seeking to work in partnership for financial reasons alone could well find themselves disappointed.
Many countries are just starting to explore the implications of new technology and are struggling with how best to understand the financial implications and the outcomes of interagency collaboration. While the rapid development of new forms of communication could revolutionise the nature of joint working, key questions remain about the extent to which these possibilities are likely to be realised in practice.
Similarly, many systems seem to be increasingly aware of the need to be clearer about the outcomes they are trying to achieve, about the economics of partnership working and about the best way of evaluating success (without necessarily knowing how best to do this in practice).
Rise of personalised care
In many countries, there seems significant potential to develop more bottom-up approaches to integration. Systems in countries such as the US, the UK, New Zealand, Australia and The Netherlands are increasingly seeking to re-engineer services to promote more effective self-care. Typically, this involves shifting away from traditional crisis services towards approaches that focus more on the needs and aspirations of the individual, working with patients, their family, workplaces, schools, communities and self-help networks.
Linked to this, many countries are also seeking to develop more personalised care and support through mechanisms such as direct payments and personal budgets – topics that are now central to UK adult social care. Viewed from this angle, integration may not be something that systems can do top-down, so much as something that people with health and social care needs can do bottom-up, integrating their own care.
This seems a challenging approach, different from previous attempts at interagency collaboration, but perhaps more in keeping with the role that service users and patients expect in designing their own support.
No single answer
Above all, an overview of international health and social care helps to make sense of the realities, frustrations and complexities of interagency working. Although different systems have their own strengths and limitations, no single country has “the answer” and there seems little doubt that the perfect organisational structure does not exist. While this might be disappointing for those hoping to import a solution wholesale from another country, it is also strangely reassuring to know that everyone else seems to be struggling with the same issues as we are.
Ultimately, the international evidence suggests that partnership working is a journey that most developed countries are on together – albeit one where no one has yet reached the final destination.
Helen Dickinson and Jon Glasby at the Health Services Management Centre, University of Birmingham, are co-editors of International Health and Social Care, published this year by Wiley-Blackwell