Integrating children's services-between aspiration and reality

Introduction: The Department of Health (DH) is currently funding several integrated care pilots in England, so called Integration Pioneers. Some local areas, however, are implementing programmes of integrated care without DH support. This paper reports preliminary findings of a longitudinal study of an integrated care programme without DH support in an urban setting in the North of England. The programme is unique in focusing solely on children's care, comprising health and social care organisations in the primary, secondary and tertiary sector. Children's services are different from adults' services by virtue of their universal funding and the holistic care approach. Nevertheless, children's health care suffers from similar organisational fragmentation and silo delivery.

Introduction: The Department of Health (DH) is currently funding several integrated care pilots in England, so called Integration Pioneers. Some local areas, however, are implementing programmes of integrated care without DH support. This paper reports preliminary findings of a longitudinal study of an integrated care programme without DH support in an urban setting in the North of England. The programme is unique in focusing solely on children's care, comprising health and social care organisations in the primary, secondary and tertiary sector. Children's services are different from adults' services by virtue of their universal funding and the holistic care approach. Nevertheless, children's health care suffers from similar organisational fragmentation and silo delivery.
Our study evaluated a 5 year integration improvement programme in an urban area in the North of England under the leadership of the local CCG. The CCG combined more than 90 GP practices, a large children's hospital with emergency, in and out patient services, and several community care trusts including CAMHS.
The integration programme is being facilitated through the work of 5 thematically defined steering groups, comprising strategic and operational staff from all participating organisations. Members of steering groups were self-selecting or were co-opted. Each working group was self-directed in defining and implementing a programme of work around integration of children's services. Themes around which steering groups clustered were 'First 1000 days' (early intervention); 'Transition'; 'Mental Health/CAMHS', 'Models of Care'; 'IT and Governance'. The programme is funded and led by a local CCG which provides administrative assistance. The programme aims to lead to the formulation of business cases for additional investment in the sector by the CCG by end 2016.
Theory/ Methods: The research study asked what the views and opinions of professional stakeholders in the programme were and how their attitudes chang ed over time as the programme progressed. It also explored to what extent staff from different organisations shared goals and objectives of the programme as they embarked on a multi-agency programme implementation. Whilst the study focused on the role of multi-agency working groups and their role in the definition and formulation of business cases for future investment, it took a novel approach in using a longitudinal methodology to investigate and monitor factors identified in the literature as contributory to multi-agency success, such as goal sharing, programme commitment and leadership, as well as perceptions of problem solving capacity.

reality.
We used an observational study design to measure attitudes of stakeholders of the programme and detect changes over time. A literature review and a series of semi-structured interviews with a purposively selected group of respondents (n=12) from organisations involved with the programme was conducted at the start of the programme in January and February 2015. Interviews were conducted face to face or via phone. They were audio-recorded with consent of the interviewee and transcribed verbatim for analysis. Transcripts were coded for themes by two independent researchers. Emerging themes were discussed to ensure consensus. The purpose of the interviews was to provide key concepts of integration programme practices to be included in the survey instrument. Key themes were grouped into 3 investigative domains.
The initial survey was to provide baseline data of staff's views and opinions on multi-agency collaboration and was repeated at 5 months with a simplified survey schedule to measure changes in attitudes. Respondents had to be members of one of the working groups to receive the survey request. All surveys were administered online with SurveyMonkey (SurveyMonkey Inc. ® (2014) Palo Alto, California, USA). Email addresses were obtained from the programme manager with the consent of all participants of working groups (n=115). Survey data were extracted from survey monkey and fed into Excel and SPSS for further analysis. Responses were descriptively analysed and cross tabulations were produced to investigate response patterns for specific professional categories or care sectors. Associations were tested using the Chi Square test.
Three domains (A-C) were investigated within the programme context: how respondents perceived the capacity of the programme to solve problems (A), whether they thought to have common programme goals (B); and what they thought the impact of the programme on current multi-agency practices was (C). Problem solving capacity was defined as 'ability to address existing barriers' and 'achieving pre-defined outcomes'. Sharing goals was operationalized as 'share the same vision what to achieve', 'share the same goals' and 'agreement on how to achieve things'. Impact on current practice was defined as 'providing increased opportunities to meet staff from other organisations'; 'increased collaborative work'; 'increased information exchange'; and 'increased awareness of other organisations and their processes'.
Results: Twenty one semi-structured interviews were conducted and responses to two rounds of the online survey were analysed (response rate 45 percent). Respondents were based in the following care sectors: Health 73%; Local Authorities 8%; Education 13%; Charities/Third Sector 6%. Findings indicate that commitment and enthusiasm for collaborative work was initially high amongst participants and remained so throughout the first year. Skepticism about the problem solving capacity of multi-agency work was however significant amongst respondents which contrasts with their enthusiasm for collaborative work. Staff from non-NHS organisations showed particularly high levels of pessimism about the programme's ability to improve service quality and service outcomes.
Discussion: Over the last two decades scholars have developed a plethora of frameworks, often followed by little empirical testing (10). Two of the more promising ones are Cohen's five organising constructs and Valentijn's model of integration. Whilst Cohen's constructs aim to structure the field and activities of integration, Valentijn's model outlines a taxonomy of integration efforts assisting in categorisation and differentiation of integration programmes. Where Cohen's constructs offer a simple 5 item overview, Valentijn's model comprises 3 main categories, 8 integration subdomains with 21 individual features.
The present study can be located within Cohen's organising constructs in the fifth domain, exploring the shared understanding of goals and vision as part of determining the model of integration, and within Valentijn's taxonomy of integration as a service or professional integration, with due nods to person focused care and guided by normative aspirations. Profession led integration pays particular attention to interdisciplinary service delivery and value added for the individual professional, leading to the formulation of a system service delivery strategy with attempts to design care plans or care pathways. The main emphasis is however on articulating, implementing and sustaining a shared vision of collaborative practice (what Valentijn calls normative integration).
The findings of the study indicate that, whilst enthusiasm for collaborative work is high amongst strategic and operational staff in multi-agency programmes for integrated care, they view the ability of the programme's problem solving capacity differently, depending on which organisation they work in. This may affect the programme's transformational capacity which appears to depend on extraneous factors such as leadership within individual organisations. It also points to the 'skin-deep' character of many integration efforts unable to challenge or transform effectively organisational cultures and sectoral fragmentation. In our study, respondents appeared to be acutely aware of this limitation, whilst continue to place hope into the programme's ability to succeed.
Conclusion: The study's findings have some important implications for programmes of service integration in the children's sector as well as general vertical or horizontal integration efforts in the adult sector. It appears that sharing goals, high levels of aspiration to overcome service fragmentation, as well as organisational commitment to improve service delivery contrast with significant levels of skepticism that integration can effectively challenge sectoral and professional fragmentation. Stakeholders appear to view organisational structures as immutable, resisting even concerted multi-agency efforts to integrate. This raises questions about the scope and depth of integration programmes (or lack thereof) as well as questions about perceptions of transformational capacity by stakeholders.
Keywords: children's services; healthcare; primary and secondary care sector; acute care; integration