Discriminación

Integrated teams, particularly those that straddled health and social care, were the focus of four of the CCG cases, but were represented in some form across all 13 CCG networks. Spanning two or more organisations, integrated roles were designed to acquire and integrate information from disparate information systems, overcoming systems capabilities. In particular, barriers between health and social care information systems were identified as limitations of knowledge acquisition and sharing among CCGs, and integrated roles were perceived as a way to overcome these barriers:

It has specifically improved communication a lot between social services and health I think. Because we both have two different computer systems we don’t talk to each.

CCG H, interview 1

This integration was seen as key for commissioners attempting to design services, as integrating perspectives and demands from multiple organisations could be seen as problematic:

It’s challenging to get that shared interpretation of what the information actually means for actual service design because clearly there are different interpretations you can apply to the same information. From a commissioner perspective, we will see a problem or challenge from one particular perspective, but health-care providers will see a very different challenge, and so we will support different

service interventions.

CCG D, interview 12

By facilitating the acquisition of diverse sources of information, integrated roles enhanced the assimilation and transformation of multiple forms of knowledge, enhancing critical review capacity of the CCG. This could enhance the commissioning process and have a positive influence on patient care, acting as a co-ordination capability. This was particularly the case for complex care provision for older people, who were often admitted to hospital in the absence of effective collaboration across health and social care organisations. Integrated care teams encouraged knowledge mobilisation across sector boundaries, enhancing service provision:

It [an integrated health and social care pathway] represents a smoother pathway for the patient. In the past the older patient would have been taken into hospital, the patient discharged, and community social care teams have little contact with what’s going on. The older patient may then be subsequently re-admitted to hospital because the social care support wasn’t there. Because we’re integrated now we can see two sides, the need for social care, as well as health care, for the patient, and so prevent readmission.

In particular, being able to take a wide view of the patient case enabled integrated teams to move past some of the potential challenges of systems capabilities, such as distinct funding streams for social and health care, which complicates elderly care provision:

I think obviously the funding bit, social care funding and health funding. They’ve both got their pots and they both want to protect their money and‘no, that’s not my job, that’s health.’ ‘No, that’s not us, that’s social care.’. I’ve really just been, you know, in the middle saying‘the person needs care. Let’s put it in and fight about it later . . . Let’s just get this care in. It’s Friday afternoon. Let’s argue about it next week’, which is how I think it’s got to work. There’s got to be somebody to draw the line, hasn’t there? I know there’s cuts and problems with funding, but the patients have got to have the care, haven’t they?

CCG H, interview 9

In one of our cases, the CCG had almost fully integrated its resources with those of the local authority. Working in the same location, sharing staff in hybrid roles (those who were employed 50% by the CCG and 50% by the local authority) and combining budgets for health and social care were seen as key mechanisms through which the CCG provided a more joined-up approach to service design:

I think I’m very, very pleased to have found that [the] CCG is able to work so closely with [the] borough council to the extent that we’re actually based in council buildings as you can see. That was never the case in the days of PCTs. There was a lot of suspicion between the two, but now they work hand in hand. That I think facilitates what you’re talking about–being able to bring in social care so that we can give people a package of care that’s not fragmented.

CCG F, interview 10

Integrating teams created a more relational approach to joined-up commissioning between commissioners and the local authority, rather than a transactional approach in which funding was a major barrier. In addition, an integrated approach positively affected the alignment of other stakeholders. For example, as a result of close working relationships between the CCG and the local authority, commissioners reported that the secondary care organisation was more‘in line’with the shared vision of the commissioning network:

To actually make all the changes that we’re going to make it’s required a lot of engagement between clinicians and directors of both CCG and the borough council and secondary care and that’s only happened because the CCG and the borough council work very closely together and there’s no suspicion anymore, so everyone’s pushing in the same direction and because of that I think that secondary care feel that . . . so you can actually get people in a room that actually will agree to things more readily.

CCG F, interview 10

The integrated teams acted as a co-ordination capability for the CCG network by encouraging the sharing of information and resources across boundaries, mediating the barriers of systems and socialisation capabilities. Although this facilitated commissioning decisions, the more important impact of integration was seen in the transformation of service decisions, having a positive impact on complex patient care:

I had a 100-year-old lady this week . . . I think third case of pneumonia, doctors wanted to admit her. She didn’t want to be admitted. She wanted to stay at home. In anybody’s eyes that’s a health need because there was a hospital admission . . . The matron phoned me up and said‘what can we do? What can you do? Do you think we ought to put care at home in?’but when I looked at the situation . . . I could have gone to the care at home team and put a team in to support her at home, but actually she was having agency care. Really good package, carers she trusted. They all really cared for her. You know, they were first name. Really good and it worked really well. So instead of taking them out and

‘it’s a health need. Let’s put health in to do it’, I left them in, looked at the contingency [fund], we had some money in the contingency, increased the care visits so they could spend a lot of time with her. So perhaps if that was cut and dried I should have used health because that was a health need, but I used social services because that was for her . . . So I think there’s ways to work round things.

CCG J, interview 9 SOCIAL INTEGRATION

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