Tightening up work

There can be few who by now are not converts to the idea of
partnership working, whether this be through conviction or simply
an acceptance of the inevitable. The number of notified
partnerships using the Health Act 1999 flexibilities continues to
rise (270 at the last count), the number of care trusts is creeping
up slowly, and the first pathfinder children’s trusts are about to
get under way. It is now time for the debate to move on to
practicalities – what has to be in place for these arrangements to
work satisfactorily?

A recent national event organised by the Integrated Care Network
(ICN) focused precisely upon some of these “nuts and bolts”
issues.¹ The joint unit of the Department of Health, the
Department for Education and Skills, and the Office of the Deputy
Prime Minister all made presentations. They were followed by six
workshops, which covered human resources, finance and pooled
budgets, sharing information, integrated commissioning, integrated
performance management, and integrating health and local authority
cultures.

Three of the issues explored are critical to joined up working at
various levels – performance management, human resources and
culture.

Performance management
The ways in which agency activity is shaped by the need to meet
performance indicators is now at the heart of public sector
management, but delegates heard that this can lead to several
difficulties in the case of integrated working.

• Reconciling the demands of the inspectorates.
  Despite recent changes, the NHS and local authorities still have
  too many inspectorates such as the Healthcare Commission, the
  Commission for Social Care Inspection, Best Value reviews, and two
  different systems for awarding star ratings. The difficulty is that
  the different inspectorates want to see what is going on in all
  agencies, even though their remit does not run to all agencies, and
  this can create confusion and duplication.
• Linking assessment to performance. Agencies
  also face the danger of spending too much time on indicators rather
  than performance – despite the fact that a poor inspection can
  outweigh a good star rating. However, some delegates questioned the
  link between star rating and actual performance, suggesting that
  some chief officers who “talk a good partnership” may not actually
  deliver the integrated goods.
• Whole system or single system measurement?
  Integration or partnership is not directly measured, so there is a
  temptation for agencies to focus upon intra-agency targets.
  However, many key targets such as intensive support to those living
  at home or the reduction of hospital re-admissions are now utterly
  dependent upon “whole systems” working, which has implications for
  decision-makers.
• For adult care, it makes sense to use the local delivery plan,
  which is strictly a primary care trust’s responsibility, for joint
  planning. It is also vital to make the experiences of users and
  carers pivotal to multi-agency data collection otherwise it will be
  difficult to have an accurate picture of services. In the past, the
  Social Services Inspectorate looked at case files and gathered user
  views, but an inspection by the Commission for Health Improvement
  might not even have included a user study. ICN delegates wanted the
  government to further streamline inspection and monitoring bodies,
  plus develop measurements of integrated working and of local
  initiatives as well as national targets. The conference heard that
  the Department of Health has now established several groups focused
  on particular client groups to review relevant performance
  indicators and to explore the development of a more joined-up
  approach in the future.

Workforce issues
If joined-up performance management is a key issue for those with
planning and managerial responsibilities, then it is the job
arrangements for front-line practitioners working in integrated
settings that are the vital “nuts and bolts” at operational level.
Several hurdles were identified and the experiences of one agency,
Sandwell Mental Health Care Trust, were explored.

• “No detriment” principle. Differences in terms
  and conditions can be a problem in joining up staff from different
  organisations, and the Sandwell response has been a “no detriment”
  promise. At a minimum, staff will retain their existing terms and
  conditions, but the avowed aim is to improve them. This can help to
  allay the fear of change that often accompanies secondment or
  transfer to another employer.
• Joined-up job evaluation arrangements.
  Although the “no detriment” principle ensures staff are no worse
  off, close working in joint teams will soon highlight people doing
  similar jobs for dissimilar rewards. The respective job evaluation
  schemes -Agenda for Change in the NHS, and single status in local
  government – are a means of addressing this dilemma. However, the
  NHS scheme is moving ahead much faster than that in local
  government, and the relationship between the two schemes is too
  loose to provide a joint framework for job evaluation.
• Dedicated time and good communication.
  Partnership working is only likely to flourish with nurturing. In
  the case of human resources this means finding time to identify and
  solve critical issues. In Sandwell, every Tuesday was given over to
  working on the workforce agenda. Effective communication is also
  vital, otherwise achievements may go unrecognised and reservations
  can remain intact.

Professional cultures
Underpinning many of the more technical issues in integrating staff
is the idea of competing cultures. Distinct cultures were
identified among front-line staff, management and bureaucracy, with
early encounters weighed down with the legacy of stereotyping. It
is precisely this idea of culture that was explored in a workshop.
Delegates identified several reasons why there needed to be a focus
upon culture.

• Culture can be a barrier to integration. This
  may especially be the case where cultural differences are implicit
  and unspoken.
• Culture is a nebulous and contested concept.
  The very fact that culture is not easy to pin down makes
  it problematic, though some delegates wondered if it was often just
  used as an excuse when negotiations faltered.
• Recognition can be a spur to integration.
  Recognising and naming the cultural differences between groups can
  in itself overcome a lot of difficulties in attempting to work
  together, but this needs the opportunity to talk and reflect in
  some depth.
• Culture is a complex concept. Some differences
  in values and meaning may seem irreconcilable, some perspectives
  may be shared, and others may be a matter of indifference. However,
  the important point is that culture does change, and with it so
  does the possibility of harmonious working between traditionally
  disparate groupings. Among the views from this workshop were that
  cultural harmonies needed to be articulated so that remaining
  differences could be dealt with more readily, and that thought
  should be given to identifying and de-mystifying different work
  cultures.

Partnership working may be regarded as now entering a final
phase. The first phase consisted of reliance upon exhortation, the
second upon the removal of legislative hindrance, and the third
upon the arm-twisting of political pressure. Now it is time to
enter the delivery stage. If joined up working cannot deliver
better outcomes for people who use services then it will be of no
intrinsic value, and we may end up with governments that hark back
to a market-led alternative. Careful attention to nuts and bolts
issues is the key to sustained success.

Bob Hudson is honorary professor of partnership studies,
Centre for Health Services Management, University of
Birmingham.

References

¹ Copies of the
presentations, accounts of the workshops and details of future
events can be found on the ICN website at
www.integratedcarenetwork.co.uk