So what do we know about the level of integration? International evidence and strategic options (“All together now?” HSM

1. Integration: Local Solutions MatterPresentation on the State of Integration in England Survey for the Ministerial Group on Integrated Workinghttp://www.integratedcarenetwork.gov.uk

2. So what do we know about the level of integration? • International evidence and strategic options (“All together now?” HSMC Birmingham, Aug 2008) • Achievements in about a dozen case studies of innovative working together (e.g “Only Connect”, Nuffield Trust April 2009 and “Partnerships for Older People” DH, January 2010) • Uptake and impact of joint finance and funding arrangements (“Means to an End”, Audit Commission October 2009) • The potential and case for more effective joined up care between health and social services (“State of Play”, Care Quality Commission, February 2010) “The level of integration between organisations had a significant impact on whether people using the services and their carers could get the right help at the right time” CQC

3. Purpose & context • The survey aimed to produce a ‘snapshot’ of the approaches to collaborative and integrated working between local authorities with social services responsibilities and PCTs • It tells us what local leaders think about the local state of integrated working – there has been no external validation on whether their views are accurate • Focus is on services for adults, focusing especially on work for the White Paper

4. About the survey: key partners • NHS Confederation • Association of Directors of Adult Social Services (ADASS) • Integrated Care Network • Department of Health

5. About the survey • Target: PCT Chief Executives & LA Directors of Adult Social Care • Distribution: survey sent via ADASS and NHS Confederation with cover letter from David Behan and Sir Ian Carruthers • Responses: 97 responses (covering 90 localities from c.150 CSSRs and PCTs)

6. Who responded?

7. Who responded? (cont)

8. Enhanced Partnership Coordination Relative Autonomy Structural Integration Joint Appointment 1. Local approach to integrated working PCT and local authority care services have formed a single integrated legal entity (Care Trust) or a combined service (joint PCT and social care department) system-wide commitment, shared vision and integration across most strategic and commissioning functions, senior & middle tier joint appointments, formal high level backing, but separate legal entities remain PCT and local authority have some key joint appointments and the teams collaborate but are not integrated/combined reasonable level of formal commitment to joint working, coordination around some areas of strategy and/or commissioning depending on circumstances Local authority and NHS meet statutory requirements for formal partnership working, but most coordination largely informal

9. 1. How localities describe their local integrated arrangements

10. 2. Client Groups - older people

11. 2. Client Groups – learning disabilities

12. 2. Client Groups – mental health

13. 2. Client Groups - children

14. 2. Client Groups - Physical and sensory disabilities

15. 2. “Substantial local focus for integration” • Respondents report greater focus on LD and MH service • 2) There is little difference between the responses of the “structural and enhanced” localities and the rest

16. 2. “Integrated working has delivered real benefit”

17. 2. Benefit is usually greater for clearly defined client groups • The responses show that the localities think that greater benefits have been achieved for LD and MH services than for Children and Older People. The Audit Commission and Care Quality Commission reach similar conclusions. • Although this is the overall pattern several localities gave specific tangible examples for benefits for Older People These were often specific integrated projects usually for early intervention and/or re-ablement/intermediate care. This dovetails with the findings from the recent DH Partnership for Older People Projects’ evaluation, • The “structural and enhanced” localities have lower scores (i.e. rate themselves as achieving greater benefits) than the other localities across all client groups. Is this significant? • The responses on physical and sensory disability show markedly higher scores (i.e. lower agreement with the statement) from the NHS

18. 3. Top factors that have helped promote integrated working locally

19. 3. Top factors that have hindered integrated working locally

20. 3. The role of the centre • None of the top 6 factors that help relate to issues that are mainly national • 20% of references to factors that help are to national issues (co-terminosity, funding, guidance etc) • BUT the top 2 and 3 of the top 5 factors that hinder are mainly national issues (performance regimes, funding and financial complexities) • 65% of the factors that hinder are mainly national issues The impact of the centre may be greater in relation to reducing hindrances than stimulating developments

21. 3. What can be done locally • The main factors that “help” are good relationships, local leadership, vision, strategy and commitment – these are locally led and owned. • Of the main factors that “hinder”, changing leadership is locally focused and organisational complexity is partly locally focused but the other factors are more nationally focused. • Friendly relationships, joint vision, co-terminosity, frontline commitment and joint commissioning are more frequently mentioned as factors that “help” by the “enhanced partnership” group than the rest • Take a strategic approach to support market facilitation and provider development • Financial complexities and culture are less frequently mentioned as factors that “hinder” by the “structurally integrated and enhanced partnerships” groups than the rest. Opportunities to link in with Total Place agenda The right local circumstances, appear to be essential to make progress

22. 3. Overall messages on “help” and “hinder” The centre can do more harm than good – it can limit local ambition and progress but it probably can do relatively little to create and stimulate joint working Some localities have found ways to address and overcome the national factors that can hinder their progress but this requires the right relationships and shared goals

23. 4. A “simple” map of local integrated working Local Authority NHS Housing Public health Adult Social Care PCT Commissioning GPs PCT Provision Children’s Social Care Education Independent providers Secondary Care

24. 4. Terminology – so what do we mean by “more” or “less” integrated working? OR More integrated working ? Individual budgets across health and social care Joint commissioning by health and social care Joint health and social care teams providing services Less integrated working ?

25. Some final thoughts • Emerging evidence from the survey suggests that to achieve better integration, there is a need for: • Better understanding of patient/user experience • Leadership and governance • Clarity of purpose locally, inc with partners • Effective commissioning • Workforce 'buy in' • Financial transparency