Differences in culture, pay, terms and conditions, targets, ethos and jargon – all of these challenges are likely to be familiar to social workers with experience of integrated health and social care teams.
Fears around job security remain high for social workers in such teams. Does integration really work? And, more importantly, does it work for social workers?
Checklist: Does integration work for you?
1. I know who my clients are
2. I know what outcomes my team is trying to achieve
3. I know what my role and responsibility is in achieving this outcome
4. I know and respect the roles and responsibilities of every other professional in my team
5. I find it easy to talk, interact and meet with the other professionals on my team
6. I feel I have influence over how the team operates and improves
7. If there are issues over funding I know how to go about resolving them
8. We have a shared terminology, and/or I understand the jargon used by other professionals on the team
9. I can access data on patients/clients kept by other professionals easily
10. We have a single referral/assessment process and there is little duplication of paperwork
11. I know what my pay, terms and conditions and pension entitlements are and who pays for them.
12. I feel my employer is fully committed to integration, including budget allocations, and job security is high
13. I have seen better outcomes for clients as a result of integration
14. I prefer working in an integrated team than a strictly social work team
15. I feel my manager understands my role, my skills, my professional ethos and my continuing professional development needs.
16. I feel confident in my supervision
17. I feel there is a good chance of me gaining promotion or managerial roles in this team.
1. I am scared my role might disappear
2. I feel isolated professionally and that I am losing my social work identity
3. I’m not confident in the professional supervision I receive
4. I do not feel able to challenge other members of the team
5. The chances of gaining promotion or a managerial role in this team is limited
6. I am constantly asked to do tasks that I feel uncomfortable about
7. I don’t believe my manager understands my professional code of conduct and ethos
8. Managers in different professions don’t seem to talk to each other or co-ordinate targets and the different terminology remains confusing
9. I am unsure about my chances of pay rises, what my entitlements are and what is happening to my pension.
10. We have separate data and IT systems and I’m not sure what information I’m allowed to share
11. Even though we work in the same office I don’t really talk to different professional members of the team.
12. We seem to treat different client groups
13. I’m not sure what targets or outcomes we are supposed to be achieving
14. The different professionals in the team constantly seem to be in conflict over meeting our different targets and performance indicators
15. Clients find it confusing what bits of service are free and what bits they are not entitled to
16. I haven’t seen better outcomes as a result of integration
17. I’m worried the team is funded by short-term funding and it will be the first to go if budgets are cut.
If you have ticked more “no” than “yes” contact your UNISON branch and discuss what you can do to improve your situation. It might also be worth speaking to your manager about your concerns and submitting them in writing to commissioners.
Integration: Four things you need to think about
Terms and conditions
Social workers can be seconded into health teams, employed by health organisations or budgets might be pooled and a new organisation created, such as a community mental health trust.
In each case, social workers will face new contractual arrangements, which can cause anxiety. Confusion around the governance rules and professional supervision can also cause tension.
“In the best schemes all of this is crystal clear right at the start for every worker involved so they don’t need to worry about it,” says Nick Goodwin, senior fellow in health policy at the King’s Fund.
Helga Pile, UNISON’s national officer for social work, points out that employers have a duty to consult trade unions who can advise members about their rights. However, while TUPE protects pay, terms and conditions, she warns employers often try to negotiate “harmonisation” agreements further down the line.
Pile favours secondments, which mean social workers maintain their link to local authority structures, keep their professional independence and ability to challenge and offer greater security of employment should the integration fail.
A recent online debate hosted by the College of Social Work’s mental health faculty showed many mental health social workers felt “frozen out” of key roles that helped shape how services were delivered.
Pile agrees that a key factor is the extent to which social care is represented within the partnership’s leadership and management structures.
“It can make a real difference as to whether social care professionals feel they are a beleaguered minority or properly respected and integrated.”
Within integrated teams there is often pressure to genericise roles and get different disciplines to take on tasks and responsibilities from each other.
Tensions often arise when staff are supervised by a different profession. Some integrated teams have separate professional and line management supervision – particularly in England where the new standards for social workers state they should be supervised by a qualified social worker.
Pile points out social workers have a professional duty to only undertake tasks they are qualified or competent to do. UNISON publishes a duty of care handbook, which helps members think about the pressures they might come under and how to act in the best interests of service users.
The Royal College of Nursing’s research on integrated teams in Scotland found that both the nurses and social workers interviewed preferred working in an integrated service than what existed before.
A social worker on Community Care’s CareSpace forum says that after having worked in four different integrated teams the benefits of better and simpler referral processes -“meaning you can find people face-to-face”- cannot be underestimated.
Case study: Freed from complications
How health and social care integration is making a difference in the Scotland highlands.
It’s 4.50pm on Friday and a GP calls a social worker requesting home care for an elderly patient. Not an unusual scenario, but the response shows the difference an integrated way of working can make.
“In this case the social worker discussed options with the community nursing team and agreed the out-of-hours nursing team would cover the weekend to allow a care at home package to be put in place for the Monday,” explains Jan Baird, transitions director with NHS Highland. “Previously this would undoubtedly have been an emergency hospital admission. I think that is very encouraging.”
The way NHS Highland and Highland Council have integrated health and social care is often cited as the inspiration for the Scottish government’s legislation on integration. However, their determination to get the planning process right means the formation of frontline, integrated teams is only now being contemplated – two years after deciding to integrate.
All adult social care staff have been transferred to the NHS and all children’s health staff, such as health visitors, have been transferred to the local council.
Each profession has a parallel professional structure alongside their line management structure.
Jan Baird, transitions director with NHS Highland, says they have worked closely with unions about the transfer of rights, which they have called TUPE+ because it also includes pension rights.
“We still have some way to go to work out how we evaluate the success of integration. But already we have seen social care and health workers coming up with solutions to problems that have never been contemplated before because they feel freed up from the former complications around budgets and accountability.”
WHEN INTEGRATION GOES WRONG
History is littered with failed attempts at integration, says Nick Goodwin, senior fellow in health policy at the King’s Fund. This leads to instability for the social workers involved, so how can you identify the risk factors for future “disintegration”?
Most of the current break-ups in England are because of funding. In Sedgefield, often cited as an example of successful integration, the co-located teams were recently split because of drastic budget savings in health and social care – with jointly-funded management posts some of the first to be cut.
Commissioners often assume that savings will be made along with improved care but this is not always the case. “Integrated teams are cost effective and some do make savings but that usually comes after the improvements in care are achieved,” says Goodwin.
“When I’m advising on projects the first thing I ask is, ‘what is the question for which integration is the answer?’,” says Goodwin. “Integration is not necessarily the answer for everything. I think you need a targeted population with a very clear outcome that you are trying to achieve. Integration upsets the apple cart in a big way so commissioners need to be sure the end product justifies the change and that everyone involves knows what they are trying to achieve.”
Integration often takes years to bed in, so short-term funding and thinking is often a key problem, as is a lack of consideration about issues such as joint IT systems, data-sharing protocols and joint training.
Alongside planning must be provision for evaluating results says Goodwin. “This is something we in the UK are not that good at. We assume that we will improve results but we don’t have anything to prove it. So as soon as cuts are made these kind of projects are the first to go.”
Better outcomes for clients
Use the audio player below to hear how Trudy Burns (above), a social worker in a community learning disability team in southern England, has made the journey to integration with health.
Trudy’s top tips for better integration
See if you can get involved in shadowing or “taster days” to see what all the other members of your team do on a daily basis. Try and encourage them to do the same with your social workers.If your area is proposing to form integrated teams do as much research as you can about how successful integration works. Ask lots of questions of managers, commissioners and supervisors about the proposed formation and structure, as well as terms and conditions, to make sure it works for you.
See if you can do joint visits with the other professionals – it will help foster better relationships and communication on cases.
Be prepared to work together constructively to find solutions when inevitable conflicts arise around different targets, culture, jargon and eligibility criteria.
Trudy Burns is also a spokeswoman for the College of Social Work.
The state of integration between health and social care in the UK
Northern Ireland – Has always had integrated health and social care teams but a major criticism is that a medical model of care dominates with social workers having little influence.
Scotland – Introducing statutory obligations on health boards and councils to integrate budgets and meet joint national targets.
Wales – The recent health strategy and five year vision relies heavily on integration allowing care to move closer to home. Integrated teams are already in place across the country to help troubled families.
England – Mental health teams have long been integrated but budget cuts and changes to law mean some are now “divorcing”. Health reforms pose a challenge to established integrated teams as the move to clinical commissioning groups will make pooling budgets more difficult. Many claim an emphasis on personalisation has also delayed integration as it complicates problems still further.
King’s Fund: Integrated care for patients and populations: A report to the Department of Health and the NHS Future Forum
Royal College of Nursing: Integration of health and social care: a snapshot
Community Care: Expert guide to health and social care joint working
Find out about the benefits of union membership for social care professionals.