El reconocimiento de las paradojas

Xyrchis and Lowton (2008) comment that as far back as 1920 the then Ministry of Health recommended that the provision of community health care would best be met through teams working in primary care. The post war period, however, was characterised by service delivery at a uni-

professional level with some pockets of integrated practice (Pollard, Sellman and Senior 2005).

More recently, the WHO (2010, p. 7) has also presented a vision for interprofessional collaboration in education and practice settings

suggesting that this would be a desirable state as it “strengthens health systems and improves health outcomes” through the process of staff from different professions working together.

Therefore, nearly 100 years after the Ministry of Health’s original

recommendation, integrated practice is a philosophy that it is suggested has not yet been achieved fully. It is still being pursued, with the Centre for Workforce Intelligence (2013) advocating for this by encouraging policymakers to recognise the need for better co-ordinated services to meet the needs of health service users.

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In order to meet the challenge of developing greater integrated working, numerous government policies may be perceived as drivers towards collaborative practice. It is accepted though that, on their own, they are not sufficient to achieve this (Barrett and Keeping 2005).

The intent of the legislative framework within the UK was to develop innovative ideas for workforce re-design across professional boundaries, encouraging flexibility in working, whilst also improving performance quality and maximising resources to achieve value for money (Irvine et al 2002, Mickan and Rodger 2005, Cameron 2011). However, Gittell (2008) recognised that in doing so this not only placed pressure on organisations to reduce costs, but also contributed to increased levels of stress for the staff who were expected to work differently to achieve this. Tensions may therefore be perceived to proliferate between the role of the

commissioners and the health and social care organisations, but also between the strategic managers and the operational staff in relation to the implementation of policies (Hoyle 2014) and changes to services. When considering the provision of clinical interventions through this process, there is also the appreciation of an increasing complexity of the needs, within contemporary services, of the service users. As a result, it is suggested that it is not possible for these to be met comprehensively by one provider or profession (Freeth 2001, Irvine 2002, Hall 2005, Wackerhausen 2009, Reeves, MacMillan and Van Soeren 2010), thereby reinforcing the need for the development of integrated practices.

A recent emphasis placed legislatively on the interpersonal element of how individuals work together, was in contrast to the more performance focused earlier Modernization Agenda. This had made the assumption that integrated partnership working across professional boundaries would energise people and would lead to a more innovative and effective use of resources as well as improving the quality of patient care through

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2002, Irvine et al 2002, Bainbridge et al 2010, Cameron 2011). Taylor and Kelly (2006) highlight that prior to the 1980s professionals were able to interpret policies using their own discretion and that their professional expertise went largely unchallenged. However, there has been greater emphasis, within policies over the last forty years, in making professionals more accountable for their actions through the introduction of a “plethora of controls and audits” (Taylor and Kelly 2006, p. 632).

Although Masterson (2001, p. 334) had previously evidenced that there was limited cross boundary working between professionals to achieve the requirements of the policies, the pressures placed upon organisations due to the emphasis of the legislative drivers on interprofessional

collaboration may be suggested to be a difficult one for practitioners to reject (King and Ross 2004), leaving them with no option but to practice in this way, if they do not already do so.

As a result, those who were in this position, may consider changes to working practices as a challenge, with Hudson (2002) concurring that the move to collaborative practice has not necessarily been perceived

positively. He reported the presence of the concept of pessimism to describe the process of attempting to develop collaboration that had taken place between some professional groups.

To demonstrate the presence of interprofessional collaboration within the legislative framework, the following offers a brief synopsis of the political drivers that were key contributors to this. Each offered specific

encouragement and expectations in relation to the development of collaborative practice, and enhanced previous policies.

Changes highlighted in “Working for patients” (DH 1989) became

legislation in the NHS and Community Care Act (DH 1990), which gave prominence to improved collaboration between professionals and

organisations, forming the foundation for modern day community care services by introducing the internal market (Day 2006).

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The internal market was subsequently replaced in the White Paper “The New NHS, Modern-Dependable” (DH 1997). This introduced a system of integrated working with the aim of further breaking down organisational and professional barriers, to enable greater joint working between health and social care organisations across defined geographical areas through the introduction of Primary Care Groups (Elston and Holloway 2001). The perception was that interprofessional collaboration and greater integrated care would contribute to achieving this.

Primary Care Groups later developed into Primary Care Trusts and were a forerunner for the existing Clinical Commissioning groups, whose impact on strategic decision making was recognised by many participants within this study as having a significant contribution to the development of their services due to the frequency of re-design requested by them.

Aiming to improve quality standards, performance related measures were introduced in the NHS Plan (DH 2000) and NSF for Older People (DH 2001b). These continued the theme of advocating the benefits of

partnership and collaboration between professions in order to improve the outcomes of patient care with the intent to redesign the service around the needs of the patient (Finch 2000). To achieve the required

performance outcomes the NSF promoted the development of integrated services within joint commissioning arrangements with the aim of

ensuring high quality services for older people (DH 2001b). Standard 3 of the NSF promoted the role of intermediate care within this, setting the scene for collaboration within this type of service.

More recent policy documents including the Health and Social Care Act (DH 2012) and Five Year Forward Review (NHS England 2014) have also placed emphasis on the Integration Agenda and in developing integrated partnership working that was patient focused, requiring the Clinical

Commissioning Groups to “promote joined up services” (Centre for Workforce Intelligence 2013, p. 4). To do so would require the

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development of new structures and models of practice to break down existing boundaries, as intervention was expected to be more person centred and seamless. This repeated the philosophies documented in previous policies.

Currently the Better Care Fund is the “only mandatory policy to facilitate integration” (DH 2017, p. 5) between public sector bodies, encouraging them to work seamlessly together to ensure a more efficient use of resources. The emphasis within this policy framework was on providing proactive care to maintain individuals within their own home, rather than requiring input from health and social care services.

Recognising the significance of the emphasis within the Better Care Fund to the study of interprofessional collaboration within this thesis, what is of particular relevance are the four metrics it proposes to measure

performance by. These are; Delayed transfers of care, Non-elective admissions to hospital, Admissions to residential and care homes and Effectiveness of re-ablement. Section 2.7 will reinforce that these were key components of the original intermediate care criteria advocated by the Department of Health (2001a) and in standard three of the NSF for Older People (DH 2001b). This therefore reinforces the continued

significance of intermediate care as a service working within the remit of the UK government’s Integration Agenda.

Whilst earlier documents had encouraged the emergence of integrated practice, there was later recognition of the need to review the training needs of staff to increase their skills to work more flexibly (NHS England 2014), to achieve the requirements of these policies and papers and deliver the new ways of working to support greater integration between health and social care services (Skills for Health 2017). The WHO (2010 p. 7) summarised this suggesting that “A collaborative practice-ready health worker is someone who has learned how to work in an

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(2017) reinforced that the Integration Agenda was here to stay and that in order for practitioners to meet the requirements of it, they would need to alter their mindset to work beyond traditional professional boundaries. Both the Centre for Workforce Intelligence report, and the Skills for

Health working paper though, did highlight how working practices could alter in order for professionals to operate more flexibly across professional and organisational boundaries, noting that this may involve changes to existing roles, or the creation of new roles (Centre for Workforce

Intelligence 2013), enhancing existing knowledge bases to meet the needs of service users of the future.

Whilst advocating this, they were also realistic enough to recognise that integration and collaboration does not just materialise because policies require them to do so and that consideration needs to be given on how to encourage practitioners from different disciplines to work in an integrated and effective way (Centre for Workforce Intelligence 2013). Through this, it could be construed that there was the recognition of the importance of developing interpersonal relationships in order to meet the demands of the policy requirements.

Furthermore, Hall (2005, p. 194) had suggested that whilst boundaries between different professions were high “they are not insurmountable”, a factor Cameron (2011, p. 53) later supplemented by advising that in order to encourage greater flexibility of working practices this required organisations to take into consideration the “human and social aspects” of this to challenge traditional working patterns. However, this had not

always been evident in the government policies published to promote interprofessional collaboration.

Therefore, although emphasis has been placed in concurrent policies on the benefits of working collaboratively to break down barriers between professions, services and organisations (Baxter and Brumfitt 2008), King and Ross (2004) reinforce that there were difficulties and tensions in

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operationalising collaborative practice, even with the political drivers in place. In spite of the continued emphasis placed on encouraging

integration between organisations, services and practitioners, it may be proposed that barriers and obstacles remain in situ which impact on its progress (Skills for Health 2017).

Based on the documents noted in this section, collaborative working has therefore been portrayed as a mandatory requirement within

contemporary health care services. Resources and competencies are encouraged to be shared, with the expectation of positive outcomes for intervention, and the re-positioning of teams along the spectrum from fragmentation towards integration.

Underlying this, Irvine et al (2002) note that with the increase in commodification of health care services, there has been greater

expectation from service providers to promote the best use of resources and ensure value for money (Hoyle 2014), due to what the NHS England’s Five Year Forward document describes as a “mismatch” between demand and capacity (2014, p. 5). As a result, traditional roles and boundaries have been challenged (Freeth 2001) to meet this disparity and strive to achieve an increase in performance with limited additional resources. To achieve this there has been an expectation of the need to introduce different ways of working at both organisational and operational levels to “help shape behaviours, actions and practices in the workplace” (Hoyle 2014, p. 194).

Interprofessional collaboration therefore tests the stability of well-

established professions. It requires staff to work flexibly and to develop new, or adapt existing skills to ensure that they have the competencies to work in different ways required by their service, with the core of the team comprising generically trained staff, supported by a small number of people in more specialist roles (Primary Care Workforce Commission, 2015).

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