Editorial

Article Type: Editorial From: Journal of Integrated Care, Volume 21, Issue 2

The concept of health and social care “system” has become commonplace within academic, practice and policy worlds. It has been used at a macro-level to map out the responsibilities, powers and resources of the various organisations and bodies, at a meso-level to understand the pressures,boundaries and influences of individual organisations, and at a micro-level to achieve improvements within direct services to patients and users. This is as true within the world of integration as in other aspects of delivery and commissioning. Indeed where the metaphor of a complex system of separate entities which inhabit similar environments, are constantly evolving to survive,and which have varying dependences on and/or power over each other seems particularly apt. As an example, the consultation on future integration in Scotland uses the term system(s) over 50 times and uses the concept to bind together the broad set of issues that are seen to prevent the achievement of integrated care:

our current system of health and social care still incorporates within it barriers in terms of structures, professional territories, governance arrangements and financial management that often have no helpful bearing on the needs of the large, growing group of older service users, and in many cases work against general aspirations of efficiency and clinical/care quality (Scottish Government, 2012, p. 12).

The articles within this edition of the Journal of Integrated Careconsider different aspects of the health and social care system and the organisational and professional boundaries that must be successfully traversed. Anna Coleman and Stephen Harris’ focus is the empowerment of one organisation in the local system to hold others to account, as they discuss the current changes in England to the role of local authority elected members in scrutinising health care services. This function was introduced in 2001 to bring local democratic accountability to the governance of NHS health care services and bodies, and will be continued and extended in the new arrangements to include the Clinical Commissioning Groups, independent sector services purchased by the NHS and public health duties undertaken by the local authority. The extent to which these committees will be given the resources to develop and undertake their roles remains to be seen though, and this stands out as an area ripe for future evaluation and reflection. Rebecca Kingsnorth uses the experiences of one London Borough to discuss the transfer of public health responsibilities across organisational boundaries. In principle this could be an opportunity to better integrate initiatives to address the broader determinants of health with strategic systems focussing on housing, education and employment. She highlights local factors which could prevent or limit the potential synergies being realised, including political accountabilities, language,criteria, expectations, vision and commitment. The familiarity of these issues reminds us of how stubborn such barriers are, despite the many attempts to change the nature and behaviour of professionals, organisations and incentives that motivate and direct them. John Skinner et al. consider the potential alignment of two strategic processes, the equality delivery system and joint strategic needs assessment. Despite their complementary objectives relating to the addressing of inequalities, the separate legislation and guidance that underpins and informs their work has often meant these systems have worked in parallel. A strong case is made for a stronger connection being made to better meet their individual requirements and achieve greater benefit for disadvantaged individuals and communities also.

The final two articles take a micro perspective of the current system through their focus on practice and people’s experience of care. Ailsa Stewart and Gillian MacIntyre researches care management Scotland and so explores one of the key enablers (in theory at least) of co-ordinated care planning and delivery. She finds that despite the local organisations agreeing shared policies and procedures the understanding and implementation of these on the ground was variable, and problems existed in transferring responsibility across professional and organisation boundaries. Whilst personalisation should lead to greater direction of care packages by the individuals receiving them, there will be many patients and users that will continue to need the involvement of a care co-ordinator. The lessons from this research are that the support systems that surround the process such as IT, management and training are as important as securing the commitment of the staff concerned. Personalisation is shown as means to drive better primary care for people with dementia in our final article. Michael Clark et al. evaluate a memory service based in a general practice in rural Staffordshire and consider the potential for vertical and horizontal integration within such a setting.

“Systems thinking” is likely to remain a common concept within integrated working for the foreseeable future. As ever, the most important test of its worth will be the extent to which the lens that it provides enables policy makers, managers and practitioners to understand and respond to the harsh financial environment in which we find ourselves. One must hope that the survival of the fittest is not the dominating principle within this system though, and that instead we are able to evolve together to achieve individual and collective strength that is focused on the needs of individuals and their families.