Evaluation of Integrated Resource Framework Test Sites

7 LESSONS FOR FUTURE INTEGRATION

7.1 One of the main aims of the IRF evaluation was to draw out implications from the findings to inform other partnerships. This included identifying lessons that may help with future moves towards financial and resource integration, both within and across health and social care services, in Scotland. Chapters 3, 4, 5 and 6 address this by drawing key findings from the test sites' experiences of undertaking IRF mapping and trialling new models of integration. This chapter pulls together an analysis of three themes (purpose, scope and drivers) which have more general application to the emerging integration agenda.

The purpose of integration

Defining the benefits of integration

7.2 The IRF aimed to inform partners of how resources are currently spent on delivery of health and social care services, enabling them to make better use of these resources in the future. To meet this aim, the Scottish Government designed the IRF programme with two key stages: mapping of health and social care data; and trialling new integrated ways of working. As the test sites undertook these two stages, partners developed individual definitions of the function of the IRF to suit their local situation. For some it was a philosophy of partnership working that underpinned future service development; for others it was a pilot initiative that provided a catalyst for trying something new; and for others it provided an opportunity to revisit previous initiatives in partnership working. The range of interpretations of the IRF helped stakeholders to accept it as relevant to their area of work but also blurred the lines between the IRF and any other forms of integrated working.

7.3 When the evaluation baseline was carried out in 2010, partners reported that the IRF was aiming to affect outcomes which would directly impact on the delivery of services (such as improved efficiency, cost savings, better quality of care, and empowered staff). However, as the evaluation was repeated in 2011 and then again at the start of 2012, the expectations of the IRF were described in terms of process outcomes (such as opening up discussion, improving dialogue, raising awareness and improving information). This shift reflected the experience of the test sites, which indicated that integration does not happen at the flick of a switch but rather as part of an ongoing process of change. Partners reported that process outcomes may - or may not - lead to more tangible outcomes such as more efficient use of resources or a measurable improvement in patient care.

Evidencing the benefits of integration

7.4 In 2009, the Scottish Government commissioned a review of international literature on the financial and resource mechanisms used to integrate care. The report of that work found that many countries are "endorsing partnership working in order to design provision around users' needs". However it also noted that it is "difficult to provide clear messages about (integrated resource models') effectiveness" and that "evidence on critical success factors tends to be anecdotal".²⁹

7.5 The IRF evaluation confirmed this finding, namely that making the case for integration is intuitively simple but evidencing and implementing integration is practically complex. Partners repeatedly reported that intuitively it is "impossible to argue against the potential of integration" and "if you were designing services from scratch you would automatically create a more integrated way of doing things". However, it was also consistently stated that the historical position is one where care is provided by a number of different agencies and organisations and weighted towards institutional settings rather than community care. Partners reported that leadership and legislation are likely to be needed to overcome the inertia inherent in this historical position.

7.6 Some stakeholders noted an apparent circularity between the need for evidence of the benefits of integration as the basis on which to build a case for implementing it and the need to implement integration in order to evidence the relative benefits. The IRF made some progress in addressing this "chicken and egg" dilemma by increasing the awareness of the value of more integrated mapping information across the test sites and within the pilots. However, the IRF test sites are only now beginning to try out new financial mechanisms under real conditions of use so the evidence base for the benefits of integration remains limited.

Understanding stakeholder expectations

7.7 It was reported that a service change that results in community delivery with a focus on enabling greater independence can, initially, be interpreted as service withdrawal and that the benefits are not always immediately clear to service users or the public. For example better coordination of services may result in fewer staff being required to deliver care but this can be interpreted by the recipient as a reduction in care. A natural predisposition on the part of both the public and staff to stick with what they know, and concern about risks in making changes to the care of vulnerable people, were reported as significant factors in inhibiting a shift in the balance of care.

7.8 Test sites reported that it can be difficult for service users and the public to accept that a change is either necessary or beneficial. Public perceptions were reported to be an important consideration where integration aimed to implement service change - particularly where a long-standing package or service arrangement has been in place - with limited evidence that current services are not working and therefore need 'fixed'. Fear of loss of services and scepticism about the motivation for change (cost-cutting rather than patient benefit) were reported to impact on perceptions of both the public and staff involved.

"Some families feel they have fought for years to get service and worry that if they agree to reduce or give up, how will they get it back if needed? It's all about good relationship and trust between families...and providers."

7.9 Expectations about what care should be available, where it should be provided and how quickly it should be accessible combine to influence the level of demand for health and social care services. A better understanding of the different perception of need held by the public, patients, professionals, planners and politicians could provide greater momentum for future work on integrating care.

Demonstrating leadership commitment

7.10 Two complementary attributes were reported to differentiate the extent to which local leaders were able to facilitate integration: clarity and commitment. As discussed above, clarity and agreement on definition of the expectations, benefits and outcomes of integration is essential. However, the experience of the test sites indicates that clarity of purpose must be matched by leadership commitment in order to create the momentum required to effect change. Strategic leadership commitment was signalled by:

• the level of seniority of individuals representing organisations at joint meetings
• the regularity of attendance by individuals (rather than sending apologies or a deputy)
• the ease with which joint meetings had represented authority to make decisions
• willingness of senior staff to take active roles in trialling new models rather than restricting their involvement to strategic planning or steering groups.

7.11 Integration was driven more quickly when there was clear leadership commitment at a Chief Executive level in both partner organisations. This was found to be useful in defining the parameters for integration and encouraging an integration culture. However, strategic direction was also notable where its absence left a vacuum in which partners struggled to make real progress.

The scope of integration

A whole system approach to health and social care

7.12 The IRF aimed to support improvement in the provision of health and social care by considering the combined resource and activity of NHS and Local Authority partners. Analysis of the mapping and trialling of new models carried out by the test sites indicated that integration would benefit from a whole system approach which would include a wider range of services (e.g. housing and education).

7.13 The IRF test sites talked of integration within the three broad areas of anticipatory care, treatment and rehabilitation. However it was reported that integrated systems need to make stronger links across these elements of care and also complete the cycle by including prevention (via public health promotion), and palliative care. In particular, it was also acknowledged that the level of demand for care needs to be considered earlier on and that the promotion of healthy lifestyles and reduction of unhealthy behaviours could have a significant role to play in controlling the level of demand required of an integrated health and social care system. Stakeholders reported that addressing problems such as alcohol and drug misuse, smoking, diet and exercise should be included in the analysis and planning of integrated care.

Complementary large and small scale integration

7.14 The experience of the test sites indicates that some form of large scale integration of budgets would be needed in order to address big financial items such as fixed costs and resource realignment. Stakeholders involved in the pilots reported limited opportunity or value in working on integrating small localised budgets without the freedom created by a much broader look at freeing up the entirety of resources of all partners.

7.15 However, the evaluation found that smaller scale integration would also be necessary within this to make manageable the network of partnership relationships and understand the needs of natural population groupings - "It's down to people knowing each other". The smaller scale integration would focus on care delivery based on geographic settings (e.g. districts or localities), care pathways (e.g. stroke rehabilitation), or care groupings (e.g. young people with complex needs).

Replicating local innovation on a larger scale

7.16 Some of the test site pilots created positive examples of service review and identified opportunities for improved integration. However, there was little evidence of work piloted in one area being rolled out or copied in other areas. Even pilots within a single NHS board, but involving only one Local Authority partner, reported that the same ways of working would not necessarily be copied by neighbouring councils within an NHS board without a similar piloting phase to test if the lessons were transferrable. Local innovation was therefore seen as creating useful case studies of the potential of change but was limited in the extent to which it impacted change on a wider scale.

Long term commitment to overcome short term challenges

7.17 There was no legal requirement to integrate, which meant that partners in each of the test sites were able to work to their own timescales. There was significant variation in progress across the pilot sites depending on the drivers, enablers, inhibitors and barriers (discussed later in this chapter). There was a consistent message from the test sites during each of the three rounds of evaluation that the timeframe for introducing integration needs to reflect the complexity of the process and the difficulties in getting the main stakeholders fully engaged.

7.18 The evaluation found evidence of a number of potential short term downsides to integration which would have to be accepted and then addressed before longer term benefits could be realised:

• The process of implementing change may incur additional costs in the short term which have to be balanced against the likelihood of making greater efficiencies or potential saving through integrated services in the longer term.
• The process of implementing change may disrupt services in the short term as providers and users learn new ways of delivering and receiving services. However, in the longer term, integrated care pathways could simplify services.
• The process of implementing change may unsettle public and patient expectations especially where they involve apparent cost cutting measures. However, in the longer term, integrated services have the potential to increase satisfaction by demonstrating improvements in outcomes and better value for money.
• The process of implementing change may increase workload pressures or job uncertainty for staff in partner organisations in the short term. However, in the longer term integrated working may lead to more efficient use of staff time across the system.

7.19 If future integration initiatives are to move beyond process outcomes and start to deliver impact outcomes then longer timeframes need to be considered. The legacy of delivering institutional-centred care via separate organisations means that time will be needed to disinvest resources and free up fixed costs (e.g. revise staffing levels and the use of buildings).

The drivers of integration

7.20 The evaluation identified two categories of drivers which could build momentum for change or act as barriers which made progress more difficult. These drivers are differentiated by the level of control that can be exerted over their direction and impact. The first category comprised of systematic levers for change over which an element of proactive control could be exerted. The second category comprised environmental and cultural drivers over which control was more limited and reactive.

Systematic levers of change

7.21 The table below lists five key levers which were found to strongly influence changes in behaviour of partners at all levels. If these are considered and controlled then they hold the potential to enable positive change. However, ignoring any one of these could turn it into a barrier.

Lever	Potential to act as a driver	Potential to act as a barrier
Policy and legislation	Consistent policy direction can encourage partners to commit to greater integration of services. Consistent policy direction can promote shifting the balance of care from institutional to community settings.	Specific policies emerging over time can lead to uncertainty about what the next change will be. Too many policy initiatives and pilots can dilute the ability of stakeholders to participate in each.
Systems and structures	Changes to governance arrangements can coordinate services and facilitate greater integration (e.g. co-location, shared assessments) Changes to financial mechanisms can allow integrated planning of budgets and facilitate transfer of resources between organisations.	Reorganisation of systems and structures takes time and effort to implement and can disrupt services during the transition. Repeated reorganisation of systems or structures can lead to uncertainty about how long any organisational structure will last.
Information	Analysis of data from partners can provide a more complete picture of service delivery to inform planning decisions Mapping information can inform analysis of variation in service provision.	Mapping information can focus planning decisions on what can be measured - which may not necessarily be what is important. Uncertainty about the validity and use of mapping data can lead to disengagement and confusion.
Incentives	Financial incentives can be used to encourage changes in service delivery. Reward frameworks such as the QOF can be used to standardise changes in service delivery.	Financial incentives can skew attention on particular areas which may be at the exclusion of newer and more innovative ways of working. If some partners receive incentives to engage in integration but others do not then this may seem unequal.
Improved outcomes	Potential improvements to the efficiency, effectiveness and equity of provision can encourage sharing of information and resources. Potential improvements to the quality of services and to patients' experience of care can encourage partners to consider integrated ways of working	Competing or conflicting objectives can act as a barrier to integration. If the improved outcomes are not communicated to stakeholders or accurately measured over time then partners may lose interest as change is perceived to become an end in itself.

Environmental influences

7.22 When the IRF programme started there was some concern reported amongst stakeholders that the wider economic environment might cause services to retreat into a culture of protectionism rather than take a perceived risk on sharing budgets more openly with partners. However, over the evaluation period, there has been a marked shift towards acknowledging that external financial pressures make it more difficult for partners to continue to provide services in the same way. This has encouraged partners to consider the potential of new more integrated ways of working.

7.23 Demographic trends were reported to act as a key driver for integration within and across the test sites. Impetus for new ways of working has arisen from the challenge of attempting to provide quality care that meets the increasing needs of an aging population within an economic climate of limited public spending. This has been accompanied by a consistent policy agenda of "shifting the balance of care" and supported by specific programmes such as the IRF and the Change Fund. Cost pressures and future demographic and care trends were reported as providing partners with an increasing motivation to change current models of service delivery.

7.24 It was noted by partners throughout the evaluation that the level of demand for health and social care services was growing. This was due not only to the demographic pressures of a population that is living longer with increased health and social care needs, but also linked to factors such as smoking, drug or alcohol misuse, obesity and mental health issues. It was widely reported that the benefits of providing more integrated services for one group in the population were not always easily identifiable, since the level of demand from other groups transferred to fill any slack in provision. Changes in these demand pressures could incentivise changes to provide services in new ways to keep up with need.

Conclusion

7.25 The IRF helped enable four NHS Boards and 12 Local Authorities to gain a clearer understanding of health and social care costs and activity. It has identified some of the limitations of current data, but also started to address some of these through national support of local innovation.

7.26 The IRF encouraged partners to experiment with new ways of jointly planning services and delivering care. Over the past two years, it has supported national policy direction to shift the balance of care and has contributed to the development of a growing culture of more integrated service delivery. Implementation of new financial mechanisms to facilitate resource transfer proved a lengthier undertaking than expected and the value of new financial models is not yet fully developed or tested in Scotland.

7.27 The evaluation has identified and reported on a broad range of lessons from the test sites. In particular, the IRF has shown the importance of: (i) clear definition and communication of the purpose of integration; (ii) sufficient scope, scale and time for integrating services; and (iii) understanding and harnessing all available drivers to engage stakeholders and deliver change. This learning should inform further development of the IRF and may well be relevant in the consideration of the emerging policy and legislation about the future integration of health and social care services.