Inter-professional working at the frontline; lessons learned from integrated care teams in Tower Hamletsrmjlmcd10 August 2018
In this post, Mirza Lalani discusses his experience as an embedded researcher in Tower Hamlets
‘The process whereby members of different professions and/or agencies work together to provide integrated health and/or social care for the benefit of service users’ (Pollard et al, 2005)
Why inter-professional working? The World Health Organisation (WHO) has stated that inter-professional collaboration is an essential component in satisfactory service delivery.
Health and social care systems in the UK are facing unprecedented pressures to manage rising demand from an ageing population, which is compounded by an increasingly demotivated and constrained workforce and the requirement to operate within tight financial parameters. Integrated care is often presented as part of the solution, as strengthening coordination between health and social care systems and among different care settings to provide joined up care that can help meet the needs of the growing number of patients with complex health and social care problems.
In 2015, the NHS England Five Year Forward View put a lot emphasis on new models of care based on the idea that care should be person-centred. One of these new models of care, a Multi-specialty Community Provider (MCP) partnership of health, social and voluntary care providers and commissioners in Tower Hamlets, was awarded Vanguard status in 2015. A key aspect of the Vanguard programme is inter-professional working, especially between frontline health and social care professionals with the goal of providing holistic care.
For the last 12 months, I have been working as an embedded researcher in Tower Hamlets spending a lot of time with frontline multi-professional teams to understand how they work. These teams include community nurses, physiotherapists, occupational therapists, care navigators and social workers working together to meet patients’ needs in their locality. The co-location of these staff is an important step towards integration, but its impact is often overstated and in reality professional culture, identity and boundaries make it difficult for senior management to realise their vision of a fully integrated, coherent and joined up health and social care service. For instance, having different management lines (for social workers on the one hand and health professionals on the other) can be a barrier to people feeling like they belong to one team.
There are some reasons to be optimistic. I have witnessed a cultural shift among health professionals, in particular GPs, who are more inclined to refer patients to other professionals when they feel there is a need for social intervention. Indeed, this shift away from a biomedical to a more psychosocial approach has seen the development of new roles within Tower Hamlets including social prescribers and care navigators. With 1 in 5 patients visiting their GP with non-medical problems such as employment, immigration, housing and welfare issues, these new roles have a significant part to play in the care landscape and should be at the centre of future system and service development. In Tower Hamlets, GPs have remarked on the crucial role that care navigators and social workers can play as there is growing recognition of issues associated with the wider social determinants of health.
The evidence for the effectiveness of improving patient and health service outcomes for integrated care has been mixed at best. Initially most integrated care programmes were based on case management, which means identifying the top 2-3% of the population (the most complex adults) most at risks of hospital admission. However, now there is increasingly a move towards looking at whole population health needs, with a stronger focus on prevention and management rather than treatment. Whether there is the capacity on the ground to do so, I’m not entirely sure. In fact, based on my emerging findings we are no closer (if not further away) from Andrew Lansley’s somewhat utopian vision of several local fully integrated health and social care systems – it could be argued that care services have actually become more fragmented due to dwindling resources, workforce shortages and low levels of morale among our frontline professionals.
In Tower Hamlets, however, there is growing effort in generating connections and strengthening relationships among different professionals and across different health and social care organisations. Multi-professional teams are an important way of addressing siloed and disjointed working and hence, addressing the differences in professional culture will be integral to enabling partnership working to be effective. This is an important lesson for those embarking on integration programmes – one person’s integration is another person’s fragmentation (Leutz et al, 1999), thus, harmonising the health and social care workforce will be a key facilitator in fostering positive population health outcomes. A bottom-up approach with empowered multi-professional teams focussed on meeting the specific needs of the local population might finally help us deliver what until now has been mainly rhetoric: patient-centred care.