Integrated team working: a literature review.

Introduction This literature review was conducted to provide a background understanding of the literature around integrated health and social care prior to a research project evaluating two integrated health and social care teams in England, UK. Methods A systematic literature search of relevant databases was employed to identify all articles relating to integrated health and social care teams produced in the last 10 years in the UK. Results Sixteen articles were found and reviewed; all were reviewed by the first reviewer and half by the second reviewer. Discussion Key themes identified were: drivers, barriers and benefits of integrated working; staff development; and meeting the needs of service users. Conclusion Recommendations for integrated working include; a focus on the management of integrated teams; a need to invest in resources for the successful integration of teams; a need for the development of clear standards for monitoring the success and failure of integrated teams; and the need for further empirical evidence of the processes used by integrated teams. These findings will be valuable for practitioners who are establishing services or want to improve integrated care in their own practice.


Introduction
This paper provides an overview, a macro perspective of the literature on integrated care in health and social care in the United Kingdom (UK); directed to an international audience to inform it of the key issues relating to integrated care. This review was undertaken to provide an understanding of the literature relating integrated working prior to commencing an evaluation of two different models of integrated working in community settings in England, UK [1]. Integration of both national health services and local government adult services is at the heart of national policy, from both a commissioning and provision of services perspective. The development of commissioning in this area is a high priority for many Primary Care Trusts and Councils within the UK.
The City Council that commissioned this research was experimenting two models of integration; one co-located health and social care team serving a specific neighbourhood, and the other a city wide service employing 'dedicated lead workers' who navigate ser-International Journal of Integrated Care -Vol. 10,29 April 2010 -ISSN 1568-4156 -http://www.ijic.org/ vices on behalf of individual service users across the city. This literature review provided an overview of integration and informed the evaluation of the service.

Definition of integration
There are numerous definitions of integration [2] but for the purpose of this paper integration is seen as the assimilation of organizations and/or services into single entities, allowing for greater transparency between partners as well as enhanced benefits for service users [3]. Through integration of services it is believed that fragmentation between providers can be minimized, this being of greatest benefit to service users, especially those with complex needs [3].
From an international perspective the idea of integrated care is relatively new, yet within the context of health care reform throughout the world, it is also very necessary. This paper provides a systematic review of current literature in this context; explores how integrated care has developed in the UK; articulates the main themes to emerge from this; and contributes by providing an understanding of the issues that impact integrated care, suggesting ways of overcoming the barriers to its success. Thus providing an insight into how internationally policy might be changed to facilitate integrated care for it to be successfully realized in practice.

Methods
A systematic literature review was conducted to investigate the evidence regarding the development of integrated health and social care teams for adults and older people in the UK. Prior to devolution, differences in health policy across the four countries had been minimal. Devolution has provided the four countries of the UK (England, Scotland, Wales and Northern Ireland) with the freedoms to pursue and develop their own health and social care policy. Subsequently, there are differences in the way integrated care has been interpreted and developed in each country of the UK [4,5].

Search strategy
The literature search involved collating information from peer reviewed articles published from 2000 onwards, to ensure up to date and relevant research was included. Multiple databases and search terms were used; search terms included 'integrated', 'inter-professional', 'health and social care', 'multi-agency', 'joint working' and 'shared services'. Databases searched were: Web of Science; the Allied and Complementary Medicine Database (AMED); the Cumulative Index to Nursing; Social Care Online; PubMed; and Allied Health Literature (CINAHL).
The inclusion criteria used were that the articles had to be research based or literature review papers about integrated health and social care teams, providing services to adults and older people in the UK. Excluded articles were those connected to children and families, and the private sector.

Results
The initial cross database search revealed 488 search results (see Table 1).
A further search using Social Care Online and PubMed exposed a further 1570 articles (see Table 2).
Titles and abstracts were read and articles were included or excluded using the criteria above. One article was unavailable and could not be retrieved by inter-library loan. A hand search revealed one additional paper [2] published following the initial database search.
The final literature review is based on 18 articles. Three of these articles [6][7][8] were based on the same data and so combined into one discussion point. Following in-depth reading of the articles one further paper was rejected [9]. This paper discussed the possible issues for holistic care in black and minority ethnic communities but little information was provided therefore the article was unsuitable for review. All the literature was reviewed by one reviewer (AB), and the second reviewer (SM-P) reviewed half of these. A critique of the selected 18 articles is discussed in Table 3 below.

Discussion
The literature review provides an understanding of the relevant literature relating to integrated health and social care teams providing services for adults and older people in the UK. In order to develop a clear narrative of the key issues, the articles are discussed using key themes evident to the authors. These themes are: models of integrated working; drivers and barriers to integration; the benefits of integrated working; issues around staff development; and important issues for service users.

Models
There is no universal definition of integration and there are multiple models of integration [2]. Coxon [10] differentiates between two models of integration-stand  staff working alongside medical staff, and the divide between these disciplines [10]. This was illustrated in a number of ways including: the differences in geographical boundaries, communication boundaries, and status inequalities [11,15]. In addition, the mismatch in cultures, behaviours and understanding of services creates a divide between the disciplines [12]. Organizational boundaries resulted in staff feeling pressured, and the process of collaborative working led to unrealistic expectations being placed on staff [10]. Other barriers included a lack of clarity of purpose for integration, and a failure to agree partnership outcomes [12].
The lack of understanding and clarity of others' roles was also highlighted as a barrier [2,18]. Lack of clarity regarding management roles and responsibilities can lead to conflict between team managers; and lead professions; imbalance of power and poor communication were obstacles [18]. Scragg [19] reports that commissioners and team managers considered the lack of control given to team managers and some not being fully committed to team working, instead being more detached. Ambivalence of some medical staff has been a barrier to integration in cross agency working [10].
Whilst integrated working provides the tools to identify client problems there is a financial limitation as to what can be addressed with the resources available. Personnel related concerns including: shortterm contract working, lack of clear career structure, and limited opportunities for promotion (unless they left the service) created a dilemma-a trade-off between present job satisfaction and future career progression for staff in integrated care teams [11,16]. Warne et al. [20] discuss the difficulties of moving to fully integrated health and social serviceshighlighting the difference between the team vision (which was overwhelmingly positive) and the findings. They argue that rhetorical claims are used to contain the good and the bad aspects of the organizational experience.
There is some evidence of integrated working improving clinical outcomes when measured by the number of older people continuing to live independently in the community following care [21]. However, Davey et al. [17] reported that regardless of care type (co-located or non co-located) it was the cognitive impairment of service users themselves that was the key factor in the clinical outcome.

Benefits
Benefits for service users and staff have been highlighted in the literature, these include: increased job alone organizations and cross-agency integration. Stand alone organizations provide the integration of health and social care to form a new service provided alongside mainstream services, while cross-agency integration brings together different disciplines in a virtual way to collaborate at service user level.

Policy drivers
A variety of drivers to integrated working had been identified in the literature. The need for clear governance arrangements has been highlighted as an important factor for integration [11,12]. There is a need for successful management of the tension between structure and culture at a local and national level, and a recognition of the fundamentally different principles of governance [12]. Another driver was the need for a shared understanding of the purpose of the joint venture and a mutual understanding of, and commitment to, the vision of the venture across the organizations involved [11][12][13][14][15][16]. It is important for integrated services to work together across agency boundaries; this has been facilitated by the removal of structural constraints through the Health Act 1999, permitting pooled budgets and integrated provision [15]. Integrated teams must be able to exchange knowledge easily between agencies; effective shared information technology (IT) systems are key to the success of integrated working [13,14].
Further drivers to integrated working included: the development of a shared culture [13]; establishment of new roles to support new ways of working [14]; coterminosity of boundaries for health and social care services [15,16]; exhibiting a past history of joint working [11]; recognition of grey areas in policy and organizational terms and encouraging local agencies to work together in those areas [15]; and the promotion of professional values of service to users and socialization into the immediate work group [6][7][8]. There is mixed evidence for the importance of co-location as a key driver for integration; while many studies have asserted that co-location is a necessary factor [6-8, 13, 15] others have reported this is not always the case [17].
With regards to these drivers it is important to understand the different priorities of front line staff to management. Managers have been found to focus on issues related to the policy implications of changes, while front line staff emphazise the need to improve the practicalities of joint working [13].

Barriers
The literature review revealed a number of barriers to integrated working. One example was social care nity groups [19]. It is also important to provide personnal and organizational development opportunities for staff, including joint activities, which may increase understanding of other disciplines [19]. One issue to be addressed is non-documentation of contact with social care; this could be addressed by the development of staff, highlighting the importance of recording all contacts made [17].
For many staff in integrated teams there appears to be a trade-off between job satisfaction and career progression [10]; the specific skills developed by integrated care workers need to be rewarded through formal pay and career structures [10]. This is supported in the findings in the final report to Stoke City Council [1].

Service users
Only two of the studies reviewed included the views of service users themselves as part of the evaluation. Scragg [19] reports that integrated service management results in services being more responsive to service users. Brown et al. [21] report that the key issues for service users were around obtaining initial access to services; many were confused about what level of support they were entitled to, and perceived the manner in which they were refused services as insensitive [21]. For those receiving care, service users reported strong bonds between themselves and their home care workers [21]. To facilitate improvements for service users there is a need for integrated services to be embedded, and for efficient and effective information systems [21], which may seem at odds with the current policy drive to personalized care.

Conclusion
Recommendations in the literature include the need for a focus on the management of multi-professional teams. This would help team managers understand their role and to enable them to reach out beyond the teams to leadership within the localities developing broader partnerships with organizations and community groups [19]. Integration of services requires considerable investment in the resources required for successful implementation of integrated care teams, as well as meeting the needs of service users [24]. There is a need for clear standards for monitoring the success and failure of integrated teams including validated measurement tools, comprehensive case studies and comparative analysis of different approaches to integration [2]. More research is needed to provide empirical evidence, grounded in satisfaction; greater team working; development of a shared culture; improved communication; and enhanced co-operation with other agencies-allowing teams to meet clients needs more easily [10]. More specifically, cross-agency working can improve collaboration while, in contrast, stand alone agencies have problems collaborating with traditional services [10,22]. The speed of response from referral to assessment can be quicker in integrated teams, and the initial stages of the process may be improved through better communication, understanding and exchange of information amongst different professional groups [21].
Mental health service users have reported that integrated team management has resulted in services being more responsive, with reduced waiting times and increased explanation of treatment by clinicians [19]. Service users also highlighted the need to include support outside of clinical areas, particularly in the areas of housing and benefits [19]. Holtom [15] noted the positive effects of transformational leadership skills, the need for an erosion of traditional boundaries, and the importance of the promotion and encouragement of positive cross agency relationships.
A key factor in this may be the personality of team managers and their ability to develop positive relationships with a wide range of staff from different disciplines [12].

Staff development
It is acknowledged that some staff members may view engaging in inter-professional practice as risky; however, establishing agreed roles and responsibilities may overcome some of the conflicts that arise for professionals [18,23]. Stewart et al. [18] suggest that the use of joint training and cross agency secondments may help prepare staff to appreciate each others roles and responsibilities.
Managers need to be aware of rhetorical defences which may be used by staff to protect themselves from the conflicts resulting from change; by encouraging staff to take time out-for instance in the form of away days-managers can provide an opportunity to engage and invest in personal, professional and organizational development, which may reduce the conflict created through integrated working [20]. By providing support and training to enable staff to work creatively, a culture that fosters integrated working maybe developed [18]. Focusing on managing multi-professional teams would help managers to understand their role, and to reach out beyond the team, to leadership within the localities, developing broader partnerships with organizations and commu-