In the United Kingdom a narrative of integrated care has been developing for a number of years, but as financial pressures on the health and care system have increased, integration has risen to top of the agenda as means of not only providing a holistic response to the needs of consumers but also reducing gaps and inefficiencies in care.
In 2014, NHS England – the strategic government body that oversees the National Health Service in England, published the NHS five year forward view, its vision for an integrated health and care system. The document focuses on two key areas: developing ‘new models of care’ in which the traditional boundaries that exist between primary care, acute hospitals, community services, mental health services, and social care in England are reformed to integrate care around the consumer; and creating a new relationship with consumers that encourages consumers to be active participants rather than passive recipients of services.
The nature of organisational integration in England may differ from that in Australia, but the role of the workforce is one that both countries are grappling with. Not only is there a need to consider the number of staff and the skills needed to deliver a more holistic approach to care, but there is also the issue of how professional roles and organisational identities can be adapted to span traditional ‘boundaries’ of in the health and care system.
A number of new roles have emerged to support organisational integration but as England embarks on service integration at a national scale, should developing new roles be part of the way forward, or are there other approaches that organisations should be considering? Research conducted by The King’s Fund, a health policy charity in the United Kingdom, has examined the current evidence around new roles and the findings of its report Supporting integration with new roles and working across boundaries provide useful learning.
The research identified a range of new roles that fell into three main areas:
- care co-ordinators and case managers who liaise between different services to ensure the care of an individual is actively managed across multiple boundaries
- roles that emerge out of existing ones by extending, delegating and substituting skills in order that staff are able to provide more holistic care
- innovative roles such as care navigators and community facilitators who reduce fragmentation and optimise use of health, social care and community services, while empowering individuals in the process.
Although the majority of these new roles were within the health system, the aim of bringing together health and social care was evident in the development of enhanced support and care worker roles to provide not only support, but also health and personal care within residential care settings.
What is the evidence to support these roles?
Many of the organisations that have developed new roles report that this creates a more flexible and multi-skilled workforce with an ability to improve access.
However, with evaluation focused on the wider processes of integration, there has been limited assessment of individual roles and whether they deliver improved outcomes for consumers.
Evidence to support the cost effectiveness of these roles is also limited. Roles that strengthen integration by reducing the number of staff who engage separately with a consumer in order to create greater continuity of care, often achieve this by employing more qualified staff, reversing the trend for using the lowest grade staff. These roles only save money if they are able to substitute other services, and if the resulting savings are greater than the cost of the role itself. In practice this has been difficult to achieve, particularly given the often substantial investment required to develop and support these roles.
How well do these roles fit into the system?
Perhaps the biggest barrier to new roles is how they fit within the wider context and culture of health and care organisations. The influence of professional identity and organisational identity is one of the most prominent and well documented. A key mismatch in integration is in how staff define and view each other’s role. At best this can create tension in working collaboratively and at its worst can lead to denigration of the individual capabilities of staff from different professions and organisations. So it is unsurprising that the developing roles that aim to bridge both sectors has proven problematic.
There are also questions around the workload capacity of individual roles explicitly developed to support integration which can result in an individual managing high caseloads of people with complex needs, or staff engaging in extended practice on top of the ‘day job’ with little support. There has been a lot of attention given to the potential for upskilling support workers to provide health and care interventions, but a lack of standardised training and differential access brings considerable challenges to development of this workforce.
Key lessons on developing an integrated workforce
The evidence on what works suggests that developing new roles may be more of a distraction than a solution. Workforce integration is only effective within a process of wider systemic and organisational integration, where there is buy-in from stakeholders and associated support to develop policies and organisational arrangements that facilitate new ways of working.
At the same time, engaging the workforce right from the start in the aims of integration, not only builds support for new ways of working, but can result in staff identifying and implementing appropriate solutions themselves. Furthermore, (and contrary to the narrative of ‘challenging professional protectionism’) evidence suggests that actively recognising and reinforcing professional boundaries can build trust and respect which in turn enables greater role flexibility.
Much of the evidence suggests that the skills required for integrated care already exist with the workforce but are insufficiently available or inefficiently distributed.
Recognising the acquisition of knowledge and skills to support integration, and developing ways in which those skills can be shared, such as cross-professional and cross-organisational training, can greatly support this process.
Organisations should not forget that consumers are at the heart of integration. Provision that is orientated around the consumer – whether it be multidisciplinary teams, such as those seen in community mental health, the development of integrating care pathways, or ‘consumer-centred care’ approaches, all aim to bring together the skills of different professions and organisations to best meet the needs of individuals. These approaches illustrate that there are already established methods for approaching cross-boundary working which optimise how the current workforce works, and new roles are only likely to emerge when there is an acknowledged need.