Snapshot of integrated working 2013
ADASS and NHS Confederation
survey of local authority and NHS
commissioners
About the survey
• Targeted Directors of Adult Social Services and Clinical
Commissioning Group (CCG) leaders
• 69 respondents: 58 Local authority (84%); 9 CCG (13%)
– Some people responded on behalf of their whole locality (e.g. one
Director of Social Services told us they consulted three local CCGs
before responding on behalf of the area)
– Two respondents did not specify (likely to be joint appointments)
• Fieldwork: 25/03/2013– 30/04/2013. Designed to take a
snapshot of progress at the ‘go live’ date for the new NHS
architecture, but this timing will have been difficult for new
CCG leaders and impacted on response rates.
• Builds on earlier (2010) survey of DASSs and PCT Chief
Executives. Some tracker questions included.
• Will follow up findings through interviews and roundtable
discussion
Local leaders report that
integration can save money and
benefit service users, patients
and carers
The benefits of integrated care:
efficiency and value
• Respondents reported that where integrated care was
achieved, it had reduced pressures on services in their
localities in the following ways:
– 57% saw reduction in delayed discharges from hospitals
– 42% saw reduction in unplanned emergency admissions
– 41% saw reduction in the number of interventions across
health and social care
– 41% saw an increase in the proportion of older people still
at home 91 days after being discharged from hospital into
rehabilitation
– 55% saw more effective sign-posting to low level
interventions (including information advice and guidance)
• Alongside this, 48% reported quantifiable financial
savings made, with 29% seeing cashable savings.
The benefits of integrated care:
patient experience and quality of life
• 46% reported that where they had developed integrated
care, it had improved quality of life for people with
long term conditions; 42% saw improved quality of life
evidenced through patient/ user surveys
• 45% saw improved patient/service-user satisfaction
• 39% saw improved carer satisfaction
• 45% saw more patient centred care
What is helping and what is
hindering? What support is
required?
What has helped integrate care?
• Leaders matter. 84% said leadership helps; 81%
identified commitment from the top as a factor helping
the delivery of integrated care.
• Both factors were among the most important in 2010,
though ‘friendly relationships’ was the top factor then
(cited by 36% in 2010)
• Joint planning /strategy (71%), collaborative working
between commissioners and providers (70%) and joint
vision (68%) also very often helpful
• In comparison with 2010, frontline staff commitment and
joint commissioning are comparatively more helpful
• Some low-scoring factors (health and wellbeing boards,
personal budgets) are at an early stage of development
– they may be more helpful in future
% of respondents ticking option
What has helped integrate care?
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%81%
71%70%68%
67%
55%54%
49%
43%42%
38%
32%30%
25%
12%10% 7% 6% 0%
Leadership, frontline staff commitment and joint
commissioning now comparatively more helpful
NB 2010 data is from analysis of free text responses whereas in 2013
respondents were given options to tick based on the factors identified in 2010 and
others identified by policy analysts
What hinders integration of care?
• Data and IT systems were most often cited as a
hindrance – by almost two thirds of respondents.
• Since 2010, organisational complexity and
changing leadership are much more often seen as
barriers - perhaps reflecting recent reforms?
• Half of respondents saw different cultures as a
hindrance – and this has become comparatively
more important since 2010.
• Payment mechanisms and financial pressures are
another key area.
• Performance regimes was the most frequently
cited factor holding integration back in 2010. This
has been overtaken by other issues.
What has hindered integrated care?
Data and IT, culture, organisational complexity and
changing leadership have risen up the agenda
NB 2010 data is from analysis of free text responses whereas in 2013
respondents were given options to tick based on the factors identified in 2010
and others identified by policy analysts
What would assist in increasing the scale, and
accelerating the pace, of integration? Themes
• Share examples of good practice (9 mentions)
• Shift financial resources / address financial
incentives (7 mentions)
• Evidence of what works (6 mentions)
• IT / information sharing solutions (5 mentions)
• Organisational stability / no more restructuring (4
mentions)
National bodies should focus on sharing good
practice and evidence, rather than more central
guidance. Practical policy solutions will be required
to address IT / information sharing and financial
incentives.
Impact of NHS reform
Working arrangements change over time
2010 -13 shift away
from ‘enhanced
partnership’ may
have reflected
disruption during
NHS reform.
However, over time
respondents expect
a shift towards
‘enhanced
partnerships’ and
more structural
integration.
Progress in much CCG-local authority joint
working, despite disruption of NHS reform
Asked about joint working between NHS and local authority
commissioners:
• 8 cited effective joint working between local authority and CCG
• 3 referred to challenges from commissioning reform: complexity in
the system, a challenge to established integration of health and
social care, and development needs within CCGs
The immediate impact of the NHS transition process has been mixed:
• “the CCG authorisation process and the closedown of PCTs has
diverted staff time away from this agenda. We have still made
progress due to the tenacity of a few individuals”
• “a change of leadership within the PCT/CCG moved integration on
quickly”
• “[relationships] are generally positive here in [county] (i.e. Between
the Council and the CCGs) [...] CCGs are particularly pressed in
terms of time/capacity.”
Health and social care leaders are optimistic
‘I believe that my local health and
wellbeing board will drive
integrated care locally’
‘I believe that we will be able to
continue to integrate care under
the new system reforms’
What practical characteristics of
integration are in place – and
which of them make a
difference?
What can we see happening in most localities?
Some characteristics only in a minority of localities
Making a difference to patients/service users
• Respondents had the greatest confidence in
arrangements which have been key features of recent
integrated care pilots:
– Initiative(s) focusing on specific population group(s)
across all health and social care services e.g. learning
disability, children with disabilities, frail elderly
– Providing clinical services through multidisciplinary teams
– Service specifications which include jointly agreed
integrated care outcomes
• ‘An ethos of shared values between organisations’ and ‘an
atmosphere of trust and collaboration’ also scored highly.
• Pathways that cross organisational boundaries and formal
agreements such as shared guidelines are believed by
most to be making a difference, as are care planning and
case managers (though these are only fully in place in a
minority of localities).
A majority were confident the following
things make a difference
Scepticism that structural solutions
help patients and service users
Three types of arrangement were rated poorly by 10% or
more of respondents:
• Integrated back office functions (28% rated 1 or 2)
• Integrated clinical services in a single organisation
(17% rated 1 or 2)
• Formally merged organisations or joint senior
appointments (10% rated 1 or 2)
These were all only present in a minority of
organisations.
Respondents were asked how confident they felt that specific arrangements contribute towards
more integrated care for patients and service users. 1 = not confident, 5= very confident. The
above aggregates scores of 1 or 2.
Where are efforts focused?
Whose care is prioritised for integration?
• All the groups we asked about (older people,
learning disabilities, mental health, children,
physical and sensory impairment and carers)
received a significant degree of priority.
• Older people, learning disabilities and mental
health are most often given a high priority;
older people are most often given maximum
priority.
• Leaders less often scored the benefit all
these groups were receiving from integrated
care as substantial.
Integrating care for older people
Older people are most often given maximum priority for integrated
care. But the benefits seen do not yet match leaders’ aspirations.
This group has risen up the agenda in the last couple of years, so
perhaps there has not yet been time for extra efforts to have an
impact. The benefits from integration reported in this survey are
typically seen in older people’s services.
Reported real benefit more closely reflects
prioritisation for people with learning disabilities
Integrated care has been a national focus for this group
for a longer time.
Integration across all relevant services
• Efforts should cover a wide range of other services.
Some priority was given to all areas we asked about
(housing, learning, leisure, environment, police and
criminal justice, local businesses).
• Housing most often seen as top priority, followed by
police and criminal justice. These are also where most
benefit is reported – though responses overall showed
some ambivalence with many rating 2 or 3 on a scale
from 1 (min. priority) to 5 (max. priority).
• Some benefit reported from integration with each service
– but people more often reported lower levels of benefit
from working with environment and local businesses.
What might the future hold?
Aspirations for integrated working
in April 2015
Delivery of integrated care
through Integrated Care
Organisations with
collaborative commissioning
arrangements with the CCG
Our “default” is “why
wouldn't we do this
jointly?”
With a strategic integrated
care plan for [our city] being
implemented in our 3 health
and care localities, overseen
and governed by our HWB.
Implementing on the ground
changes to our services,
workforce, estates and
financial models to deliver
integrated care services for the
20% most high need citizens
in [our city].
Aspirations for integrated working
in April 2015 (contd.)
Robust pooled budgets for
certain service areas, joint
contracting/commissioning
approaches and integrated
teams (service delivery).
Realistically, this will not be
achievable across all
service areas, probably just
a few to begin with.
Strong equal partners with
shared objectives
cooperating – avoiding risks
of mergers and takeovers
A single health and social
care organisation with one
governance structure and
a single budget