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The widespread deaths of the elderly in care homes that occurred as a result of poor decisions by government at the start of the COVID-19 pandemic, revealed the lack of knowledge about how the care sector works.
COVID also highlighted the challenges of managing public services and responding to ongoing uncertainty. This includes ensuring that different, but related, services such as health and social care, join up successfully.
The idea to integrate public services has been a trend across western Europe relatively long before the pandemic. In Scotland, for example, a flagship social policy centres on the need to integrate social care, historically managed by local government, with healthcare – historically managed by the NHS. The desire to integrate these two key services has been ongoing since 2016, commanding widespread political support.
Europe-wide research, including some from Scotland, has highlighted the leadership and management challenges around the issue. From these studies, seven key lessons have emerged will help to ensure the successful integration of two of our most important public services.
1. Proper political support is required
Without sufficient central government support, innovative and creative attempts to integrate often fail – as happened with the UK’s Sure Start children’s centres. A programme designed to improve the prospects of children in deprived areas, its ring-fenced budget was removed and the initiative suffered from cuts. This led to a sharp fall in the numbers of children attending and benefiting from Sure Start – many of whom lived in the poorest areas of the country.
This is what happens when government – central or local – takes a hands-off approach to the integration of health and social care and bears no responsibility for its progress (or lack of it) at local level. Government must be held to account for the way it rolls out and maintains national public policies.
2. Community involvement is key
Support from local groups and community involvement is a predictor for success in integrating these services. Although health and social care partnership areas can help local groups and organisations work together (there are 31 in Scotland, for example), concerns have emerged over quality and accountability of services once they are outsourced to other sectors, such as voluntary or private. But outsourcing is commonplace within health and social care, and is how public services are often managed. There must be better government oversight of the outsourcing process, and acknowledgement of how communities themselves can shape health and social care.
3. Professionals must be prepared to integrate
Sometimes those working in health and social care are reluctant to integrate. Professional boundaries relating to differences in status can create friction. Differing health backgrounds – some based on medical training and some based on social care training – are often barriers to professionals coming together.
A mismatch in cultures, behaviours and understanding of services can create a divide between health and social care. This in turn, makes it harder to establish a clear purpose and agree on longer-term objectives for integration.
Multi-agency team managers need to reach out to the local community to develop broader partnerships. It is also important to provide staff development opportunities, working across this divide to improve understanding of other disciplines.
4. Shared values and goals are fundamental
For services to work together successfully, there needs to be a common purpose. Strong, effective partnerships depend on the commitment of those taking part. Defining a clear purpose at all levels is key, as well as clarifying roles and responsibilities to engender trust, understanding and respect.
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5. Clarity: accountability, communication and data sharing
Strong relationships and effective communication are key to successful integration. In practice this means both at worker-to-worker level and worker-to-client level. Collaborating and sharing relevant information between agencies requires shared management systems with common IT systems and formal agreements on things such as data sharing and constructive performance management systems.
6. Short-term funding doesn’t work
A long-term funding model is crucial for effective inter-agency working. For integration to work, there needs to be sustained funding through budget sharing, realistic staffing and timescales – with time built in for planning, and proper support. Insecure funding is a barrier in the long-term.
Currently, the integration of health and social care in Scotland, for example, doesn’t have a sustainable funding model due to the state of public finances (which are linked to austerity measures), coupled with the high costs of an ageing population.
7. People need to know if they’re getting it right
Developing the skills of managers in health and social care is important because not everyone possess the tools to evaluate what actually works. Often there is heavy focus on performance monitoring over investigating the actual changes that have emerged from integration initiatives.
National government agencies which regulate and inspect health and social care need to provide practical ongoing research support to help professionals continue their learning and access the expertise and resources they need to know what works.
When it comes to integrating public services, the “how” is just as important as the “why”, and strong leadership is important. Policymakers need to listen to those on the frontline and demonstrate that their knowledge and experience are valued. For the general public, integrating these two services will mean receiving joined-up care and support when they need it most.
John Connolly has received funding from the Scottish Improvement Science Collaborating Centre to undertake research into the leadership of health and social care in Scotland.
