‘Improving GP-social worker relationships, not structural change, should be integration priority’

By Jeremy Cooper, director, iMPOWER

Last year we pushed social care directors and health professionals to heed the warning offered by our Home Truths report and subsequent ‘on the ground’ programme.

Home Truths exposed a dysfunction at the heart of the relationship between social services and GPs, a fundamental lack of trust (for example 59% of GPs think they are a better judge of a patients social care needs than a social worker).

Since working with a host of councils through the Home Truths programme it has become clear that this is not an isolated issue. Relationships, both across professional agencies and within them, are not as strong as they could or should be.

Ultimately the goal should be the creation of a trusted community offer of care. To deliver this however there needs to be a major push to factor in the behaviour of professionals within the system.

This means not just a commitment to a change in culture but also the creation of metrics to measure and track the strength and vitality of our professional relationships.

However, I recognise that this is unorthodox for many people and to be widely accepted we need to establish some core founding principles.

To this end we’ve begun to work with our partners to formulate a pledge. A pledge that should be a feature in all Better Care Fund (BCF) plans.

The Home Truths Pledge:

1. We acknowledge that behaviour at the frontline drives the health and care system – the ‘frontline’ includes patients/services users and professionals.
2. We will seek to influence whatever positively impacts this behaviour and appreciate this will drive demand for services.
3. Delivering a ‘bottom-up’ cultural transformation is essential to deliver better care and sustainable health and care
4. This will be and remain a major theme in our change and integration plans – both in words (e.g. our BCF text) and our actions (e.g. our BCF schemes).
5. We commit to collecting and sharing data on relationships, behaviour and trust.
6. Our focus on influencing frontline behaviours is predicated on improving the experience and outcomes for patients/service users.

From the plans I’ve seen so far the focus on the behavioural and relational aspects of care integration are sporadic at best.

When one considers that the central purpose of the BCF is to integrate two competing service offerings it’s clear that reshaping the relationships and interactions of those actors within the services is critical.

Drawing on the experience of our work with the Home Truths councils, a significant step in the right direction would be to create and vertically integrate a set of relationship metrics into current BCF plans. This would then create the appropriate trigger for the right behaviours from staff to develop affiliations and build connections across agency lines.

On the face of it the challenge is one of deciding what metrics to use, and this would be an understandable but incorrect reaction. To decide your metrics, you must first agree what behavioural changes you hope to elicit based on which relationships you hope to build and at what level.

Take our original point regarding GPs and social workers and avoidable referrals to residential care as an example where limited practical action could yield significant results.

The numbers are encouraging, we have calculated that roughly 60,000 older people could be kept out of residential care every year, equating to a very conservative annual saving of £604m. This could be achieved by each council targeting the 25% most influential GPs (the highest potential referrers).

In practical terms this would mean working closely with just 52 GPs per local authority on average to build stronger relationships through a knowledge-building programme (this could include increased regular contact, intelligent sign posting, relationship metrics and the creation of a shared performance dashboard).

Put in another way, all we need is for each of these 52 GPs per authority to influence differently less than 8 older people per year to deliver this projected national saving.

Thankfully, the organisations we’re currently working with have embraced the message of the pledge are committed to taking it forward as they move along the BCF journey.

Our worry is that because too many organisations are still too focused on structural integration they will completely ignore the critical truth that behaviour at the frontline is what drives the health and care system.

Without a change there, there will be no meaningful change at all.