Editorial

Editorial

Editorial

Article Type: Editorial From: Journal of Integrated Care, Volume 21, Issue 4.

As this edition of the Journal of Integrated Care went to press, the issues of collaboration, partnership and integration were centre stage in English policy debates. Although Wales, Scotland and Northern Ireland have all been debating such issues for some time, the re-emergence of “integrated care” as a hot topic in England is more recent. In the last month, policy makers have announced plans to create a series of new “integrated care pioneers” to help develop new approaches and produce local and national learning about the barriers and success factors around more joined-up care. The 2013 Spending Review also announced greater pooling of NHS and social care funds with a view to promoting more integrated care. On one level, the signs are positive that the issue of integration is at last getting the attention it deserves.

However, underneath these various announcements there is a more complex reality. Joining up care has long been a policy aspiration (probably since the very creation of the NHS, but certainly since the 1960s) – but delivering it in practice has proved much harder. With major structural changes in the English health and social care system in recent months, there has been significant loss of organisational memory, widespread staff turnover and an undermining of previous working relationships. It is also less than clear whether there is really appetite for some of the more fundamental changes that might be needed to remove key barriers. As just one example, the Dilnot Commission and the Care and Support Bill could be an opportunity to debate whether maintaining the traditional distinction between free health care and means-tested social care makes any sense whatsoever in an era of demographic change and long-term conditions – but you can bet your bottom dollar such issues won’t really be on the table. Similarly, New Labour's suggestion that Health and Well-being Boards could become the central feature of a more local government-led approach to health and social care commissioning has gone down like a lead balloon in some quarters (see volume 21.1 of this journal for a special edition on Health and Well-being Boards).

Instead, readers of the journal know deep down that change is likely to come bottom-up rather than top-down. This is probably most clearly stated by US commentator Walter Leutz when reflecting in this journal on his seminal “five laws of integration” (Leutz, 1999, 2005). For him, “all integration is local” (i.e. it has to be a locally appropriate solution and relevant to the local context, with the role of central government or national bodies primarily around removing barriers rather than dictating what should happen). This is something that has always been crucial to readers of and contributors to the Journal of Integrated Care, and a key focus has always been on bottom-up innovation, local good practice and evaluation and reflections on the way in which local context shapes what is possible and desirable in terms of health and social care services.

In this edition of the journal, Imogen Blood builds on work for the Joseph Rowntree Foundation to explore the relationship between housing and care for older people. Despite looking at schemes across the UK, this research drew directly on the experiences of older people, their families and front-line staff to identify key barriers and success factors. Vidhya Alakeson adopts not just a national perspective, but also incorporates international learning from her work around personal health budgets. Despite this depth and breadth, her research and practice development work always retains a strong focus on the individual, how they want their life to be and how personal budgets can help to join up care and support bottom-up in a way that makes sense for the person. In Herefordshire, Mike Coupe provides a detailed case study of joint working, stressing the importance of local context in shaping what was possible and what a good outcome would look like for local people. Ryan Woolrych and Judith Sixsmith explore the concept of integrated care within the context of services for people with dementia, stressing the importance of both of flexibility and of continuity of care. Finally, Helen Dickinson and Jon Glasby report on the different meanings, processes and outcomes of joint commissioning, and the need for clarity between key local and national actors if these are to be achieved. In all these papers, there is something really important about the quality of our relationships – and no amount of national policy attention can mandate better relationships top-down.

Jon Glasby, Robin Miller and Helen Dickinson