To create harmony, we must investigate discord (Plutarch): The relationship between General Practice and social care - Learning from the Home Truths programme

Introduction: Integration between health and social care systems is recognised as vital to improving outcomes for older people. Whilst we know that integrating systems and processes is important, the basis of integration between the sectors must start with positive relationships between individuals in the system. In this paper we focus on professionals within the English health and social care system who have the closest links with, and influence over, older people – i.e. GPs and social workers. England’s GP service is often hailed as an example of good practice, but we do not fully understand the relationships between GPs and social workers; or the relationships between these professionals and older people. In particular there is a lack of research about the way in which GPs interact with social workers and the social care system as a whole. We also are unaware of how far GPs influence older people’s decisions about social care. This paper summarises an evaluation of the Home Truths programme, which sought to explore the perceptions and relationships between GPs and social workers; identify how GPs view and refer to social care services, and to develop new ways of strengthening relationships. It identifies the challenging issues raised about the key relationships between health and social care professionals and suggests some implications for the way in which we implement the integration of the health and social care systems. Theory and methods: The evaluation of the Home Truths programme sought to explore:


Abstract
Introduction: Integration between health and social care systems is recognised as vital to improving outcomes for older people. Whilst we know that integrating systems and processes is important, the basis of integration between the sectors must start with positive relationships between individuals in the system. In this paper we focus on professionals within the English health and social care system who have the closest links with, and influence over, older peoplei.e. GPs and social workers. England's GP service is often hailed as an example of good practice, but we do not fully understand the relationships between GPs and social workers; or the relationships between these professionals and older people. In particular there is a lack of research about the way in which GPs interact with social workers and the social care system as a whole. We also are unaware of how far GPs influence older people's decisions about social care. This paper summarises an evaluation of the Home Truths programme, which sought to explore the perceptions and relationships between GPs and social workers; identify how GPs view and refer to social care services, and to develop new ways of strengthening relationships. It identifies the challenging issues raised about the key relationships between health and social care professionals and suggests some implications for the way in which we implement the integration of the health and social care systems.

Theory and methods:
The evaluation of the Home Truths programme sought to explore: • what sites had hoped to gain from their involvement with the programme, • what issues the programme had raised for them, • the impact of working with an external change programme • what interventions sites were planning to implement to address the issues raised, and • what, if any, impact there had been from their involvement with the programme.
The evaluation was carried out through semi-structured interviews with key stakeholders from across the health and social care sectors who had been closely involved in the Home Truths programme in each of the six sites.
The Home truths programme was developed by iMPOWER consulting and involved stakeholder engagement, quantitative and qualitative research with GPs, older people and other stakeholders across six local authority areas in England. In total 154 GPs and 225 older people were involved in International Journal of Integrated Care -Volume 14, 01 October -URN:NBN:NL:UI:10-1-116187-http://www.ijic.org/ the research. The sites were subsequently supported to develop initiatives to address the issues raised. The theory underpinning the work was based on initial research that suggested older people were entering residential care too early because GPs did not understand the social care alternatives on offer, and that GPs had a significant level of influence on older people's decision making about social care. The improvement process was based on the assumption that the process of gathering local data and the findings themselves would act as catalysts for change.
Results: Consistent findings emerged from across the six sites. These included: • a lack of knowledge and understanding amongst GPs about social care services. Where the GPs did know about services there was a view from some GPs that those services were not good quality.
• Relationships between GPs and social care were seen as poor, but GPs wanted to learn more and improve links, as they recognised the potential of social care services to keep older people out of residential care. • GPs have a significant influence on older people's decision-making about care options; this was made more significant by the finding that older people don't pre-plan their entry into residential care.
• There were problems with communication around referral and assessment processes. Although for most of the sites the findings did not come as a surprise, having clear data about the problems in the system gave the individuals in different parts of the system a focus around which to base discussions on how to address the issues. Each site worked with iMPOWER to identify actions that could be taken to improve relationships, improve knowledge and to simplify referral and assessment processes. These discussions were turned into action plans. Sites planned a variety of approaches which can be summarised as actions to: • Improve communication about social care referrals • Improve access to information about social care services • Train GPs and consultants about social care services and processes • Embed joint working between social workers and GPs • Influence the influencers of older people's decisions about care The evaluation found that the implementation of initiatives to respond to the findings are at an early point and impacts on user experience, practitioner behaviour and use of resources will not be achieved until a later point. However, the interviewees were confident that the interventions being developed will deliver benefits and have the potential to make longer term savings through reducing or delaying older people's entry into residential care. One site in particular has committed to making a large budget saving through its plans.
Sites were positive about the value of working with an external organisation to implement the programme; reporting that access to unbiased, robust evidence had facilitated conversations between people that might not have been possible before; there was useful cross fertilisation of ideas from other sites and it brought a priority and focus to the agenda.

Discussion and conclusion:
The Home Truths programme has had a clear impact on the sites' understanding about the challenges they face in integrating the health and social care system. They have found that in order to facilitate an integrated approach they will all need to accept and address some challenging issues around knowledge, understanding and perhaps ultimately trust between the health and social care sectors. Although it is too early to be able to assess the impact of the Home Truths programme on the experiences and outcomes for older people, the anecdotal evidence from the sites suggest that they anticipate making measurable impact in the near future. The Home truths programme has raised significant challenges and insights for the areas involved, which will be of interest to other areas looking to integrate health and social care. We suggest that the sites should continue to measure the impact of their approaches, so that the results and learning can be shared more widely. The evaluation suggests that all areas could benefit from developing different approaches to integration that focus on these relationship issues in addition to the structural and service approaches being developed. Health and Well Being Boards could usefully consider how these issues might apply within their health and social care systems and initiate a constructive dialogue between partners about the relational aspects of integration.