Cuts making it more difficult to achieve health and social care integration, warns research

Pilots to test new ways of integrating care report struggle to engage frontline professionals as they "firefight" to keep services running

Increasing financial constraints on councils and NHS bodies are making it harder to achieve integrated health and social care, government-funded research has warned.

The study also found that engaging frontline staff in initiatives to integrate care was proving challenging in a climate where they were “firefighting” to keep existing services running.

Health and social care were beset by an “integration paradox” in which the financial environment made it ever more important to integrate care but, at the same time, made it more difficult to make progress in doing so.

The findings came from an early evaluation of the integrated care and support pioneers programme, a Department of Health initiative set up in late 2013 to test new ways of integrating care for people who needed the support of multiple care services.

The study, by the Policy Innovation Research Unit, assessed the initial 14 pilots from January 2014 to July 2015 and was largely based on interviews with 140 council, clinical commissioning group (CCG), NHS trust and voluntary sector staff involved in pioneers.


The pioneers started with ambitious visions to transform care in their areas for people with multiple long-conditions and frail older people by shifting services out of hospitals, reduce costs and improve people’s experiences of care.

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They had plans to use a wide range of initiatives to meet these objectives including multi-disciplinary teams, improved access to services, rapid response teams to reduce avoidable admissions, telecare and telehealth, increasing the use of community resilience and personal health budgets.

But the researchers found that over time their ambitions appeared to have become more limited and focused on “short-term, financially driven goals”, mainly around containing hospital admission and discharge costs.

Also, the range of initiatives used had narrowed to setting up multi-disciplinary teams, improving care planning, creating a single point of access for services and using care navigators to provide people with information and advice on accessing care.

Barriers to integration

Interviewees identified a number of barriers to and enablers of integration. Most of the enablers were local factors. These included the relative simplicity of organisational structures, with the best arrangement perceived to be when a pioneer involved just one council, CCG and NHS trust with similar boundaries. The most important of the enablers was perceived to be staff involvement in integration initiatives and the extent to which they felt ownership over them.

However, the report found that professional boundaries and cultural differences between health and social care staff were also barriers to integration. Interviewees identified difficulties in encouraging staff from different professions to trust one another or to motivate staff to become engaged in integration initiatives when they were “firefighting” to maintain existing services.

Interviewees felt the cuts to local government and financial constraints on the NHS were limiting their ability to reshape services. For example, initiatives to develop communities’ resilience were undermined by cuts to services such as befriending services, lunch clubs and peer support.

Also, the pioneers were not given dedicated funding, hampering their ability to initiate changes to services.

Integration paradox

Over the course of the fieldwork, researchers found that the balance between barriers and enablers were, if anything, shifting towards the former as the financial situation deteriorated.

“This was resulting in an ‘integration paradox’,” said the report. “Growing need and declining budgets provided an even stronger imperative for more effective integration. However, at the same time, this context made it more difficult to make progress.”

The context increased the incentives for organisations to “defend existing roles and resources for fear of something worse”.

The research team has been commissioned by the Department of Health to do another evaluation of the pioneers programme running up to 2020.


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2 Responses to Cuts making it more difficult to achieve health and social care integration, warns research

  1. Anonymous May 13, 2016 at 6:04 pm #

    And who exactly was meant to provide the funding? The government? The public? The NHS? It’s no good having idealistic goals, but not figuring out how you’re going to go about it. And social integration isn’t always that effective anyway, because it depends on whether the individual person wants it in the first place.

  2. Ellie May 19, 2016 at 1:52 pm #

    No offence, but I’m going to be blunt here… THIS IS SOMETHING I’VE BEEN SAYING (AND INDEED WRITING ABOUT) FOR YEARS.

    Several of my recent responses to Community Care articles have highlighted the problems with integrating NHS and Social Care services, even where it is necessary to do so. I have described in some detail the difficulties produced by ever-spiralling budget cuts, and I have pointed out the fact that the NHS cannot deliver its services, and continue to function, without the aid of Social Care. I have even drawn directly upon personal experience, describing some of my time spent in 2 different (and allegedly integrated) teams – one a Hospital Discharge Team where integrated working clearly was NOT working, and the other a Forensic Service delivered by the NHS and Social Services, which did seem to work.

    Now, what I cannot help but wonder is just WHY this research you describe even needed to be undertaken, and at just WHAT cost. If, as the Government endlessly claim, we are in a recession – which is allegedly the reason for all the budget cuts that the NHS and Social Services face – then WHY spend money on research that may not really be necessary? My point is that I will most likely NOT be alone, and certainly NOT the only person with Social Work experience, who could write or speak about the problems facing integrated teams, or the paradox of integration. Frankly, this is an issue that could be spotted by anyone with a modicum of common sense! So, WHY NOT JUST ASK SOCIAL WORKERS THEMSELVES?!

    It is blatantly obvious that, when Social Services and NHS budgets are SEPARATE, they may feel that the Government unfairly makes spending cuts in one area but not the other. To have separation such as this creates a sense of competition between the NHS and Social Services – they compete for funding in the knowledge that money is supposedly tight. Now, this may not be an accurate view of the situation; indeed, it may well be that as far as the Government are concerned, Social Services and the NHS are not expected to compete for funding, and rather, get funding from two different “pots” in order to eradicate any competition. Sadly, it may be that staff, themselves, do not perceive it the same way. Instead, all they see is a shortage of money, and that the Government makes cuts in one or the other service – NHS staff perceive cuts to THEIR services as unfairly favouring Social Services, and vice-versa. Indeed, this problem is NOT just one between the NHS and Social Services; it is endemic throughout the whole Public Sector. There is a sense that Policing, Firefighting, Youth Work, Probation Services, Social Services, Teaching, the NHS… indeed, ALL public sector professions are competing with each-other for cash from the Government. This is made much worse by the sense that they are the ones being hardest hit by the recession; almost as though they have become a sort of “scapegoat”. They did NOT cause the recession, but they are facing budget cuts. By contrast, the reckless bankers and estate agents, whose inappropriate lending DID lead – at least in part – to the recession still receive hugely inflated bonuses, and massive salaries.

    Adding to the above problem, is the issue of what I call “divide and conquer” within the whole of the public sector. I have described a little of this above, in which I stated that it seems that public sector workers have a sense of having to compete against each other for funding. My point is that the public sector professions are NOT a unified workforce. Instead, they have become a series of what I might only term “professional cliques”. each profession has its own job title, role, and thus identity – entry into a “professional clique” is dependent upon a worker having that same job title, role and identity. These cliques do NOT mix unless they have to (i.e. unless they are obliged to co-work); they do NOT train together; they do NOT have common targets or goals or values (or if they do, they don’t recognise this); they do not share knowledge, ideologies, ideas or research (again, unless they are made to); they rarely meet up with each other; and, finally, they occupy separate workplace premises. In brief, what this means is that Nurses are Nurses and think only of nursing; Police are Police and think only of policing; Doctors are Doctors and think only of medicine; Teachers are Teachers and think only of teaching; Social Workers are Social Workers and think only of Social Work… You MUST get my drift by now? There is NO evidence of common ground between the cliques, and they do not actively seek it. What common ground there might be is overlooked, ignored, side-lined or never even thought about. Why? because each profession is so tied up in trying to maintain and promote its own identity. Maybe to understand me better, here, you try reading about THE SOCIAL PSYCHOLOGY OF IN-GROUPS AND OUT-GROUPS. I’ll point you to this as a starter…

    What the above article will show you is that people tend naturally to form cliques – or, rather, ignorant and unenlightened people tend naturally to fall into cliques. Once in a clique, people tend to show a marked preference for the clique they are in; this becomes their “in group”. An “in-group” can be hostile towards non-members, who thus present as “out-groups”. This “in-group” versus “out-group” hostility and lack of identification serves to maintain a constant divide. In my eyes, THIS is happening amongst public sector workers. They identify as “in-groups” according to job title, and treat “out-groups” with suspicion, ignorance or sometimes hostility. Certainly, they do NOT identify simply as one huge, unified group of Public Sector Workers. If they did, I have NO doubt whatsoever that the workforce, and indeed individual professions within it, would be much stronger and much happier as a result. There is a huge strength in numbers to be had here. Imagine if ALL the public sector decided to come out on strike every time cuts were threatened, even cuts that affected just one area or profession? There is NO way that such cuts would prove easy to make.

    I find it borders on hilarious to read the results of the research… with an expression on my face that registers little other than “told you so”! I mean, if staff are endlessly faced with cuts, that lead to dwindling resources, is it any wonder that “ambitions appear to have become more limited and focussed on short-term financially-driven goals”? I’m sorry to have to say this (no, I’m not!), but it does not take a genius to work THAT out! Less available cash equates with more obsessing about where to find cash. As the meerkats would say… “Seemples”!!!!

    Might it also be that ambitions are limited because, pardon me for saying this, the ability levels of some staff are equally limited? I recall the Hospital Discharge Team in which worked. They DID NOT want new ideas, innovation, new staff, changes… Their “mantra”, for that is how it sounded, might well have been “this is how we’ve always done it, and we won’t change”! If you tried to suggest new ways of working, or improvements, during team meetings you would be politely ignored at best, shot down in metaphorical flames at worst.

    My point, here, is that ANY DEPARTMENT or ANY SERVICE and the way it works is only ever as good as its staff. Where staff fear change; are lacklustre, or burned out; where staff have low qualifications, or a background history of failed qualifications or having to repeat qualifications to pass them; where staff act as cliques in which existing staff reject new staff… all of these are issues which, to me, signal problems. Staff who fear change make it impossible for innovation and improvement to happen, because they blindly cling to what is safe – the past. They fear anything that takes them out of their comfort zone, and so will continue to use outdated practices; some of which should be rendered obsolete; quite simply because this is all they know, and all they want to know. Lacklustre and burned-out staff obviously will not achieve much, as their motivation and energy levels are so low that they are probably capable of doing only the minimum required to keep their jobs! Such people doubtless do not wish to have to think in creative and innovative ways. Poorly-qualified or unintelligent staff are, quite simply, unsuitable to the job that they are doing. My point, here, is this… Surely any employer would want the VERY BEST people working for them. Thus, why take staff who have only scraped poor qualifications, or had to re-sit endlessly to pass a qualification? This shows that, even before they started their job, they were not achieving much – they are NOT high achievers. WHY would you want a LOW ACHIEVER working for you? People who do not do well at school have already shown that they are either
    a) NOT academic, and NOT capable of passing qualifications – thus any training that they receive they may struggle with. They have proven themselves incapable of learning rapidly and effectively.
    b) LAZY or UNCOMMITTED. Some people fail at school because they do not make any effort. True, there are kids who do not work as hard as they could have, but still come out with good qualifications. These kids perhaps need to be given extra encouragement to work harder, as they have shown they do have potential. However, kids who leave school with no qualifications, or only a tiny few at very low grades, despite having every opportunity, should ring employers’ alarm bells. These kids have shown that they could waste time and opportunities in class, which other kids did not waste. They have also shown that they had no respect for education and that they did not value good qualifications. Indeed, it shows that they were perfectly happy to waste time at school leave with no qualifications, but still expect to be given a job (did they really think they could easily find work with no qualifications? or did they hope to rely upon nepotism or cronyism to get there?). Or, perhaps, that they had simply planned to do nothing but sit about all day after leaving school (living off rich relatives? or the welfare state?). It demonstrates a total lack of forward-planning, and a thoughtless need for reliance upon others to constantly “bail them out”. All of this says NOTHING GOOD about such a person. Indeed, it suggests an individual who is lazy, complacent and has a huge sense of entitlement! What on earth would anyone want to employ such a person for?

    Employing staff with a lack of vision, or a lack of basic ability, is a recipe for disaster – especially if these are more senior staff. Such people will be unable to lead from the front, as they do not have the capability to do so. Any ideas they put forward – if indeed they put forward any ideas – will NOT be their own. They will, instead, pilfer and plagiarize the ideas of others, further creating hostility because hardworking staff feel unrewarded, and also stifling the progress of staff who truly do have ability. Incapable staff often become BULLIES, because they see their more capable colleagues as threats. This results in workplaces where highly academic or qualified staff may be singled out for bullying; some workplaces will even lack such highly academic and qualified staff altogether – either because they left due to bullying, or because they were never hired in the first place (a poorly qualified manager will not hire somebody who is better qualified than him/her because this person may take his/her job). Staff who lack capability are rarely innovative, because this means leaving their comfort zone. Instead, they will cling rigidly to practices that seem familiar to them, even where such practices are outdated or ineffective. Such staff may also fear, or resent, additional training requirements; believing either that they do not require more training because they are already doing the job, or fearing being unable to do well.

    Alternatively, in some incompetent staff, we may see confidence bordering on arrogance. Such people will endlessly push for extra responsibilities – for example a poorly qualified Nurse who wants also to become a pain specialist Nurse despite not even being degree-level qualified. Others will endlessly push for promotion, or for being leaders of new projects or pilots. They do this irrespective of their individual capability levels, quite simply because they do not see themselves as incapable. Again, more on this can be learned from Social Psychology, which describes two interesting phenomena:

    1. The “Peter Principle” in which employees get promoted only to the point where they reach their level of incompetence (which also means that as a result, managers will often be incompetent) – for this read

    2. The “Dunning-Kruger Effect” or “illusory superiority”, in which unintelligent and incompetent people tend to believe that they are far more intelligent and competent than they actually are, whereas intelligent and competent people tend to underestimate their abilities. This suggests that it is likely that in any workplace, it is LESS ABLE people who will put themselves forward for promotion and suchlike. The competent staff will likely not do so, as they underestimate their capability. For this read en.wikipedia.orh/wiki/Dunning%E2%80%93Kruger_effect

    Staff acting as “cliques” is another form of “in-group” versus “out-group” hostility, so refer to above for this…

    Community resilience is a big thing… and a variable thing. Some communities are naturally better, and more resilient, communities than others. Perhaps the issue here is more one of identifying just what contributes to community resilience, and what destroys it? I can imagine that there are many factors that will negatively impact on community resilience, most of which are demographic in nature, including:

    1. Poverty and high unemployment.
    2. High numbers of homeless, and poor housing conditions, or high house prices.
    3. A transient community – for instance large numbers of economic migrants in that area, or refugees, or maybe a large travelling community such as Romanies, or migrant workers.
    4. A disproportionately high number of people reliant on welfare benefits – obviously, this impacts upon poverty, as well as the cost of delivering services to people who do not work and are state dependent for income.
    5. Poor levels of skill, academic ability, qualifications and education – especially if local schools are failing of poorly performing. Also if schools are overcrowded, and underfunded.
    6. High levels of crime – again, especially if local policing services are overstretched and underresourced. Combined with high unemployment, poverty, poor education, homelessness and substance misuse and this is a nightmare!
    7. High levels of people suffering from problems like drug or alcohol misuse; learning disability; physical disability, mental illness. Especially in combination with any of the other factors.
    8. “Ghettoization” – where there are communities within communities, often hidden. These may be made up of foreign immigrants, or of different social classes. Sometimes, a “ghetto” mentality may consume a whole council estate, or area of a town, because the people there live a very different lifestyle to everyone else. However, the result is that the do not integrate into the wider community, or are not allowed to integrate into the wider community. Instead, they live in a segregated fashion, sometimes to different rules or codes of conduct. Council estates may suffer from this problem quite simply because they become “dumping grounds” for all the unemployed, or elderly or disabled people from a community who are grouped together because of their need to rely on social housing and welfare benefit handouts. “Ghettoization” works much like “cliques” or “in-groups” and “out-groups”. (See reading).
    9. An extremely high elderly population, or, conversely, high teenage pregnancy rates – because these necessitate the delivery of specialized services.

    Other factors that may impact upon inability to integrate are problems with the ability to visualize effective integration, and understanding just what integrated services should be doing. By this, I mean that where we start out with separate services that need to better integrate, we are uncertain as to how best to go about this. Perhaps it becomes a process of trial and error? However, this trial and error approach will have consequences for patients and service-users. Instead, might it not be better to “model” potential integrated services? To carry out exercises in which those tasked with integrating services explore in advance the different ways in which this could be achieved, analysing the pros and cons, working through any glitches in a hypothetical manner, before integrating for real? Such exercises could also harness information and insight from a variety of different staff, gaining their individual and differing perspectives, so as best to see the matter from everyone’s angle. This allows us to envisage the potential impact for different types of staff, and roles, and how they will need to change to integrate. It may also help throw up suggestions as to how to do this.

    There are goodness knows how many barriers to effective integration, and could write for HOURS on this subject. It baffles me as to why costly research was needed, when ASKING STAFF might have been a beneficial exercise. As pointed out earlier, it does not take a genius to see what is going on to prevent integration. However, the way things are going, it WILL be a genius who is required to make integration finally work!