David Stott is Professor of Geriatric Medicine at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow and is Editor in Chief for Age and Ageing journal.
Integrated health and social care has been promoted as a key solution to the challenge of providing high quality care with a restricted budget. Philp summarises current thinking in a New Horizons article recently published in Age and Ageing.
The aim of providing a fully integrated system including coordination of organisation of health and social services sounds sensible. After all who would argue for disintegrated and disorganised care?
However there are problems and challenges, not with the concept of integration, but in the organisation and systems that are being ‘pushed’ to effect integration.
Systematic patient assessment, using tools such as the US developed Inter Resident Assessment Instruments (interRAI) or EASY-care are sometimes promoted as a key step in enabling a properly integrated system of care. However concerns have been raised over the time required to do assessments and that evaluations that have so far been performed do not provide convincing evidence of health gain or value for money. Furthermore it is not clear that the adoption of such tools will solve the main challenge in health and social care integration – which is the development of effective working relationships across service boundaries. This requires good systems of communication – which all-too-often is remote and disjointed with little or no face-face contact of workers across service divides. There are lessons to be learned from what we know works in Comprehensive Geriatric Assessment (CGA), where the Multidisciplinary Team (MDT) meeting is generally recognised as the focal point of team communication, when information can be shared, and a consensus reached in planning care and treatment and setting goals. Regular face-face contact seems to be important – and perhaps this is what we should push for in integrating services.
The subject of how best to organise and integrate care is ripe for further research! Obtaining reliable evidence does not always require a randomised controlled trial. Such studies have high internal validity, but all too often are not representative of the ‘real world’. There is a range of alternative study methods for health service evaluation – the optimal study design depends on the research question(s), but can include qualitative studies (eg to establish perceptions of services), interrupted time series, and phased implementation such as using a stepped wedge design. Simple before and after quantitative studies on a single site are highly subject to bias, and in general should be seen as unreliable as an evaluation method.
Given the current uncertainties, it would seem rash at this point to invest a lot of effort and spend large amounts of money on complex systems to try and integrate health and social care. However simple approaches to improve communication surely could be implemented (and evaluated) at little opportunity cost; it is difficult to believe we can’t do better even within existing scarce resources.