Closer integration of health and social care, proposed as a solution to simultaneously reduce expenditure, relieve pressure on key services and improve the outcomes and experience of system users1, hinges on placing patients at the centre of service design and delivery and ensuring effective communication and coordination between health and social care services. This requires collaboration, not only at a provider and local level, but also at a system level, ensuring governmental ministries and departments work in tandem to provide the infrastructure and allocation of resources needed for integrated services.
Different countries have different governmental structures, which means that experiences with developing integrated services can differ immensely. A good example of this is the United Kingdom: while all four nations have free healthcare at the point of use, only Northern Ireland has integrated health and social care at departmental level (since 1973); in England, attempts to bring social care in line with primary care pathways in the form of the ‘Better Care Fund’ have only recently started to gain traction.
Co-ordinating resources or pooling budgets between health and social care services can enable effective cross-sectoral collaboration. The following case studies demonstrate how this has worked in practice across three different healthcare systems.
Put patients at the centre of service design and delivery and coordinate health and social care services
Governmental ministries and departments must work together to deliver integrated services
Pooling health and social care budgets can enable effective cross-sectoral collaboration on early intervention
Below are case studies from Wales, Ireland and Spain, providing examples of how cross-sectoral collaboration has worked in these countries.
Wales case study
Ireland case study
Spain case study
Case study: Wales
Brief history of integrating services
Since the passing into law of the 1998 Government of Wales Act – the first of the major devolution deals – the Welsh National Assembly has had the power to enact health policy. The 1998 White Paper on health in Wales ‘NHS Wales: Putting Patients First’ was the first step towards providing patient-centric and locally led integrated care services, noting that the 22 newly created Local Health Groups (that were mapped over the 22 local authorities) would allow for healthcare professionals, local authorities and local people “to take the lead in organising health services for their communities”.2
However, although it was recognised that the Local Health Groups had generally been successful in developing partnerships with their respective local authorities, the relatively small size of these organisations meant that they were unable to either engage effectively with the seven larger NHS Trusts that spanned multiple Local Health Groups, or respond effectively to significant shifts in the external environment.3
In 2009, the Welsh Assembly published the ‘One Wales’ document that dramatically redesigned the structure and provision of health services in Wales, and aimed to bring care closer to patients in the community. The 22 Local Health Groups and seven NHS Trusts were replaced by seven Local Health Boards that were given the power and responsibility to plan, fund and deliver all primary care, hospital and community services for a given local area, in effect putting an end of the purchaser provider split. These bodies are supported by three all-Wales NHS Trusts covering cancer care and specialised services, ambulance services, and public health.
Cross-sectoral working in Wales
The Social Services and Well-being (Wales) Act 2014 mandated closer working between Local Health Boards and Local Authorities, and established seven Regional Partnership Boards to drive the regional delivery of health and social services. In particular, the Act referenced the need to prioritise the integration of services for the following:
- Older people with complex needs and long term conditions
- Children with complex needs due to disability or illness
The Act established the concept of ‘pooled funding’ between Local Health Boards and Local Authorities4, but most importantly, created the infrastructure for the efficient allocation of resources provided by the £50 million Intermediate Care Fund in 2014/15, £20 million Intermediate Care Fund in 2015/16, and the £60 million Intermediate Care Fund in 2016/17. The official guidance for the funding states that the Regional Partnership Boards will “lead on the planning and use of the funding, as well as ensuring delivery, to maximise outcomes for people and the effective and efficient use of resources”.5 Professor Longley indicated that the Local Health Boards had shown promise, but were still early in their development.
The Health Boards also work in tandem with the 22 local authority-run Public Service Boards (renamed in 2016, previously Local Service Boards), which are tasked with improving the general well-being of a given area by “strengthening joint working across all public services in Wales”.6 These bodies unite local authorities and Local Health Boards and are vital for assessing ‘local well-being’ and developing ‘local well-being plans’.7
Initially intended to be non-recurrent, the original Intermediate Care Fund was renewed in 2015/16 and again in 2016/17. NHS Wales’ official report into delayed transfer of care (DToC) – currently the only measurable of improved integration of services – highlighted that the simultaneous fall in number of beds and DToCs “showed clear signs of the positive work that is taking place across Wales to address this challenge.”8
Although Professor Longley outlined that DToCs are a poor metric by which to measure integrated care programmes – instead there should be more attention given to cost savings – he noted that improvements in DToCs, while difficult to isolate to one factor, can be explained at a local level by integrated discharge teams, i.e. teams of healthcare and local authority/housing staff that work to ensure the availability of accommodation on discharge from hospital. £10 million of the £50 million Intermediate Care Fund is allocated for such schemes and a further £4 million for supporting independent living at home.9
As an example of how this can work in practice, the Cardiff and Vale University Health Board, set up in 2009, have fully integrated district nursing and housing in a single communications hub.10
However, although there was also a recognition that there are now “good” working partnerships between primary/community and social care services in Wales, the report noted that Health Boards and Local Authorities were still operating independently from one another. Where there had been successful integration between organisations, it was suggested that this was due to “local champions”, and more needed to be done to overcome the challenges posed by different drivers, targets and employment rights.
Professor Longley outlined that accountability structures in health and social care at national and local levels had not been developed sufficiently.
Case study: Ireland
Brief history of integrating services
Until 1970, the provision of healthcare services in Ireland was organised based on county boundaries and overseen by local authorities. This was because when services had initially been designed, the funding and administration of health services stemmed from the Minister of Local Government and Public Health. The 1970 Health Act radically changed this structure and reorganised the delivery of services by creating eleven regional health authorities. In 1999, eight board became eleven when the largest was split up into three separate boards. Each health board consisted of senior clinicians, Department of Health officials and local authority councillors.
In 2001, the policy ‘Primary care – a new direction’ sought to effect change in the primary care sector, making it the cornerstone around which the wider health services are built.11 The strategy proposed horizontal integration of care through the introduction of interdisciplinary teams working in primary care that included the following: GPs, nurses/midwives, health care assistants, home helps, physiotherapists, occupational therapists, social workers, community welfare officers and pharmacists. Among the actions required to implement this strategy, community-based diagnostic centres were piloted, mechanisms for active community involvement in primary care teams were established, and closer integration between primary and secondary care was pushed (vertical integration of care).12
However, with the complexity of this structure which saw healthcare services delivered in a fragmented fashion by a number of different Government agencies, it had become increasingly complex to provide consistent health services across the whole of the country. Recent surveys have suggested that only one third of GPs felt they belonged to a functioning PCT.13 And following the passing of the Health Act in 2004, this regional system established in 1970 was overhauled and streamlined into a single national health service, the Health Service Executive (HSE) which came into force in 2005. This operates through four regions and 32 local health offices (LHOs).
The Integrated Services Directorate of the HSE manages all hospital and community public health services, including primary, community and continuing care services.14 Services are delivered through the LHOs.
Following the 2012 reforms put forward in ‘Future Health – A Strategic Framework for Reform of the Health Service 2012–2015’, which stressed the need for better integrated services, Integrated Service Areas were developed to “ensure maximum alignment between all service providers at the local level; (ii) review executive management and governance arrangements; and (iii) inform new structures for the delivery of primary care”.15
Cross-sectoral working in Ireland
In 2013, the Irish Government released ‘Healthy Ireland – a framework for improved health and wellbeing 2013–2025’, a policy that aimed to improve the health and wellbeing of a generation by reducing health inequalities and creating an environment where all sectors of society contribute to health and wellbeing.
To implement ‘Healthy Ireland’, a framework for action was developed around six themes:
- Governance and policy
- Partnerships and cross-sectoral work
- Empowering people and communities
- Health and health reform
- Research and evidence
- Monitoring, reporting and evaluation
It proposed a shift towards a broader, more inclusive and holistic approach to governing the health of the nation, looking beyond the Department of Health as the key actor, towards other Government departments, national and local authorities and all sectors of society. This involves effective collaboration across public services concerned with social protection, children, industry, food safety, education, transport, housing, agriculture and the environment.
The Cabinet Committee on Social Policy, chaired by the Prime Minister’s office, oversees the implementation of the strategy at a national level. All government departments are represented to address common policies and actions.
Healthy Ireland recognises the challenges posed by working across Government and notes that “deliberate efforts” must be made the promote this working. Proposed are the following:
- inter-ministerial and inter-departmental committees
- cross-sector action teams
- joined-up workforce development
- legislative frameworks
One such cross-ministerial team is the Health and Wellbeing Programme established in the Department of Health that works with policy units in other Government departments “to produce integrated co-ordinated intersectoral plans to address risk factors and social determinants of health”.16
An early example of cross-ministerial output from the Health and Wellbeing Programme is the Healthy Living and Active Living Programme (HEAL).
As part of HEAL, the 2015 National Sexual Health Strategy was delivered by the Department for Health and Department for Education and Skills, and the National Physical Activity Plan announced in 2016 which aims to get at least half a million more Irish people within ten years to take regular exercise – the €5.5 million plan was delivered by the Department for Health and Department for Transport Tourism and Sport.
Healthy Ireland Working in Partnership
The drive to reform the delivery of health services outlined in Healthy Ireland resulted in the establishment of the Health and Wellbeing Division in the HSE in 2013, and the reconfiguration of Integrated Service Areas into nine Community Healthcare Organisations (CHO) in 2015.
The Community Health Organisations are mapped over nine regions of varying geographies, but with broadly similar populations. The size of the CHOs were developed to be large enough to support organisation and business capability, but small enough to provide the local community connection17. The CHOs unite under one management structure a leadership team comprised of inter alia primary care, social care and residential services, mental health, health and wellbeing and general practice. As part of planning, CHOs work with the Department of Health, Department for Education and Skills and Department of Jobs, Enterprise and Innovation to ensure the future supply and deployment of healthcare workers.
Chief Officers lead local management teams and are directly accountable to delivering services to local populations. They work in tandem with on average 10 Primary Care Teams which now have specific leaders assigned for each team with protected time from their day job to perform the role.18 They also work alongside with wider public service organisations such as local authorities, child & family agencies, education and local voluntary organisations.19
The Health and Wellbeing Division within the HSE directly supports the Chief Officers of the CHOs in the development of local adaptations of the Healthy Ireland Plan, supported by an online toolkit.
Implementing HI in the Health Services
Six Steps for Implementation
Source: Health Service Executive 2013
Community Health Organisations
The development of the nine Community Health Organisations was only finalised in Q4 2016, but the structure has been identified as the future of healthcare delivery in Ireland. In March 2017, the Irish Government announced that they would be putting forward plans to “dismantle the Health Service Executive”.20
In its place, a national health agency would oversee the functioning of Hospital Group and Community Health Organisations which would assume greater decision-making powers and accountability.
An Outcomes Framework is being developed by a cross-sectoral working group under Healthy Ireland. As such, concrete outcomes remain difficult to assess.
Case study: Spain
Brief history of integrating services
The Spanish Constitution of 1978 gives all citizens rights to equal healthcare protection and assistance. In Spain, healthcare system decisions depend on the Ministry of Health, Social Services and Equality, the Ministry of Employment and Social Security and, at regional level, decisions are taken by the so-called autonomous communities, who each have their own parliaments and can decide and implement policies on healthcare.
The General Health Act of 1986 united all existing public health and welfare resources into a single mechanism based on Social Security resources, integrating health promotion and disease prevention policies and activities with medical and pharmaceutical services.
All autonomous communities have the power to manage their own services and are responsible for the administration of education, health and social services and cultural and urban development.
While the Ministry of Health and Social Policy in Madrid defines the national legislative framework for the Spanish national health service, each region is required to compile detailed ‘health maps’, which set out the services that will be provided to its population. Regions are given the flexibility they need to raise additional funds for healthcare provision through regional taxation.
Cross-sectoral working in Spain
The Inter-Regional Council of the National Health System (CISNS) is the body responsible for the coordination, cooperation and liaison between central government and autonomous communities’ public health administrations. Its purpose is to promote the cohesion of the National Health System through an effective and equitable guarantee of the rights of citizens throughout the country.21
The Advisory Committee of the CISNS comprises the same groups, but also sees membership extended to business organisations and state-level trade unions. However, while the CISNS comprises representatives predominantly from different Health departments – Ministry of Health, Social Services and Equality and the Regional Ministry of the autonomous communities– it nonetheless represents an interesting example of cross-ministerial collaboration for healthcare systems that are devolved regionally. The CISNS and Delegate Committee (second level) meet at least four times per year, while the working groups and technical committees work more frequently.22
In 2011 Basque Country in Spain launched a strategy to promote person-centred care for patients with chronic conditions to tackle the increasing burden of chronic conditions, Strategy to tackle the challenge of chronicity in the Basque Country.
According to the Basque Health Survey carried out in 2007, 41.5% of men 46.3% of women were suffering from at least one chronic health problem23. As highlighted in the below infographic, the prevalence of chronicity had increased notably in the past decades.
In 15 years the prevalence of chronicity in the Basque Country has increased notably throughout the region (%)
Source: ESCAV 1992, 1997, 2002, 2007
The strategy led to significant changes in the way care is organised and delivered locally in the region. Similarly to the other regions in Spain, the Basque Country has an NHS-type healthcare system, characterised by universal access for its population – the Basque Ministry of Health oversees the funding, planning and management of the health system and ‘Osakidetza’ – the Basque health service – is in charge of the provision of public health care services.
However, primary care organisations and hospitals were run on a separate basis, with no shared objectives set for the different levels of care. To tackle the challenge of chronicity the new strategy aimed to guarantee continuous care through the promotion of a multi-disciplinary care programme, co-ordinated and integrated between the different services, care levels and sectors.
This would be achieved with two types of initiatives:
- The coordination of care processes between primary and secondary care, through the design and implementation of better clinical pathways for high impact and prevalent chronic conditions. To implement this several tools were established including the introduction of multidisciplinary teams, technical boards and mixed clinical committees.24
- The promotion of organisational integration through the creation of integrated healthcare organisations (IHOs), merging hospital and primary care structures under one single organisation to achieve better quality of care and efficiency.
In practice, this also mandated an integration of IT systems, joint-working arrangements and coordination and joint-action between the Basque Government, County Councils and Town Halls. The following infographic outlines a reformulated version of the 1998 Chronic Care Model for the Basque region.
An IHO pilot project was launched in 2011 with the Bidasoa Hospital and three local health centres to test the new organisational model. The success of this project guaranteed the up-scaling of it across the Basque country so that all primary and secondary care centres of the region would operate under this new integrated model by the end of 2016.
Adaptation of the care model for Chronic Patients in the Basque Country
Source: Developed by Ed Wagner and collaborators from the MacColl Institute for Healthcare Innovation. Adapted by O+berry Basque Institute of Health Innovation
The results from the Bidasoa project have showed great promise, with a decrease in the rate of hospital admissions (−38%) and A&E admissions (−31%) for patient with multiple morbidities alongside improved patient experience figures: 87% percent of patients stated that hospital and primary care coordination was “good”/“very good” and 66% that coordination between health and social services was “good”/“very good”.25
Framework for cross-sectoral collaboration
The following framework was discussed with Professor Longley as one to support the implementation of cross-sectoral collaboration:
1 Parliamentary Office of Science and Technology. (2016). Integrating Health and Social Care. Available at: http://researchbriefings.parliament.uk/ResearchBriefing/Summary/POST-PN-0532
2 NHS Wales. (1998). Putting Patients First. Available at: http://www.wales.nhs.uk/publications/whitepaper98_e.pdf
3 King’s Fund. (2013). Integrated Care in Northern Ireland, Scotland and Wales. Available at: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/integrated-care-in-northern-ireland-scotland-and-wales-kingsfund-jul13.pdf
4 Social Services and Well-being (Wales) Act. 2014. Available at: http://www.legislation.gov.uk/anaw/2014/4/pdfs/anaw_20140004_en.pdf (p.119)
5 Welsh Government. (2016). Intermediate Care Fund Guidance 2016/17. Available at: http://www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/160418intermediateguidanceen.pdf (p.7)
6 Welsh Government. (2016). Public Service Boards. Available at: http://gov.wales/topics/improvingservices/public-services-boards/?lang=en
7 Welsh Government. (2015). Shared Purpose: Shared Future. Available at: http://gov.wales/docs/desh/publications/161111-spsf-3-collective-role-en.pdf
8 http://www.ssiacymru.org.uk/resource/dtoc-report-final–eng.pdf (p.5)
9 Welsh Government. (2016). Intermediate Care Fund Guidance 2016/17. Available at: http://www.housinglin.org.uk/_assets/Resources/Housing/OtherOrganisation/160418intermediateguidanceen.pdf (p.7)
10 Cardiff and the Vale University Health Board. (2014). Gateway for Independent Living. Available at: https://www.valeofglamorgan.gov.uk/Documents/_Committee%20Reports/Cabinet/2014/14-05-12/External-Funding-Applications—ICF—Appendix-A.pdf
11 Department of Health and Children. (2001). Primary Care: A new Direction. Available at: http://health.gov.ie/wp-content/uploads/2014/03/primcare-report.pdf (p.7)
12 Darker, C. (2014). Integrated Healthcare in Ireland – A Critical Analysis and a Way Forward. Available at: https://www.tcd.ie/medicine/public_health_primary_care/assets/pdf/Integrated-Care-Policy-LR.pdf (p.26)
13 Darker, C. (2014). Integrated Healthcare in Ireland – A Critical Analysis and a Way Forward. Available at: https://www.tcd.ie/medicine/public_health_primary_care/assets/pdf/Integrated-Care-Policy-LR.pdf (p.35)
14 Citizens Information. (2013). Health Service Executive. Available at: http://www.citizensinformation.ie/en/health/health_system/health_boards.html
15 Department of Health. (2014). Future Health. Available at: http://health.gov.ie/wp-content/uploads/2014/03/Future_Health.pdf (p.iii)
16 Department of Health. (2013). Healthy Ireland. Available at: http://health.gov.ie/wp-content/uploads/2014/03/HealthyIrelandBrochureWA2.pdf (p.19)
17 Health Service Executive. (2013). Community Healthcare Organisations. Available at: http://www.hse.ie/eng/services/publications/corporate/CHO_FAQ.pdf
18 Health Service Executive. (2013). Community Healthcare Organisations. Available at: http://www.hse.ie/eng/services/publications/corporate/CHO_FAQ.pdf
19 Health Service Executive. (2013). Community Healthcare Organisations. Available at: http://www.hse.ie/eng/services/publications/corporate/CHO_FAQ.pdf
20 Irish Times. (2017). Simon Harris to propose major changes to health service structure. Available at: http://www.irishtimes.com/news/ireland/irish-news/simon-harris-to-propose-major-changes-to-health-service-structure-1.3016669
21 Ministry of Health and Consumer Affairs. (2008). National Health System. Available at: http://www.msssi.gob.es/en/organizacion/sns/docs/Spanish_National_Health_System.pdf
22 Ministry of Health, Social Services and Equality. (2016). Interterritorial Council of the National Health System. Available at: https://www.msssi.gob.es/organizacion/consejoInterterri/aspectos.htm
23 Ministry of Health and Consumer Affairs. (2010). A Strategy to Tackle the Challenge of Chronicity in the Basque Country. Available at: http://www.osakidetza.euskadi.eus/r85-gkgnrl00/es/contenidos/informacion/documentos_cronicos/es_cronic/adjuntos/ChronicityBasqueCountry.pdf
24 Polanco, N. T., Zabalegui, I. B., Irazusta, I. P., Solinis, R. N. and M. D. R. Camaral. (2015). Building integrated care systems: a case study of Bidasoa Integrated Health Organisation. International Journal of Integrated Care, 15(2). Available at: http://www.ijic.org/articles/10.5334/ijic.1796/#fg0004
25 Polanco, N. T., Zabalegui, I. B., Irazusta, I. P., Solinis, R. N. and M. D. R. Camaral. (2015). Building integrated care systems: a case study of Bidasoa Integrated Health Organisation. International Journal of Integrated Care, 15(2). Available at: http://www.ijic.org/articles/10.5334/ijic.1796/#fg0004