Progress in partnerships

Defining Pooled' Place-Based' Budgets for Health and Social Care: A Scoping Review

Introduction

Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target 'places', broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches.

Methods

We initially conducted a scoping review, a systematic database search ('Medline', 'Embase', 'Econ Lit' and 'Google Scholar') complemented by further snowballing for academic and 'grey literature' publications (1995 - 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.

Results

Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.

Conclusion

Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Organisation of care: Primary care organizational responses to mental health needs

This paper considers a number of factors that give renewed prominence to organizational dimensions in developing primary care responses to mental health needs as the context for a new collaborative research programme in this area.

A typology is proposed to describe a range of organizational responses to mental health need in primary care. This serves to draw attention to the fact that research and practice and service development have tended to focus on organizational arrangements that clarify the relationship between primary care and secondary mental health services and relate largely to the care and treatment of people with severe and enduring mental illness, with considerably less exploration of other forms of organisational responses for different types of mental health need.

The authors conclude by suggesting the need to develop greater understanding of lay perceptions of mental health and mental health needs, along with further exploration of help-seeking behaviour and of factors that promote self-care.

Going round in circles? Joint working between primary health and social care

Purpose

– The purpose of this paper is to examine research evidence on collaboration between primary and adult social care in strategic, rather than operational, activities at two different time points, following large-scale changes within the health and social care environments; and discuss the prospects for the future.

Design/methodology/approach

– This paper reports evidence from two substantial longitudinal studies (Dowling and Glendinning, 2003; Checkland et al., 2012) which followed the development of Primary Care Groups and Trusts (PCG/Ts) and Clinical Commissioning Groups (CCGs), respectively. Each used a combination of national surveys and local in-depth case studies to trace the early development of new structures and ways of working following major changes in the NHS and local government.

Findings

– PCG/Ts had limited success in collaborating with adult social care partners. Health and Well-being Boards offer a new overarching organisational framework for collaborative strategic working between GP-led CCGs and adult social care services. Mandated joint strategic needs assessments also provide a shared framework within which commissioning decisions by both CCGs and social services are made. However, there remains evidence of long-standing barriers, particularly differences in geographic boundaries and in organisational and professional cultures.

Research limitations/implications

– Evidence from both studies is based on the early years of the respective new organisations; later evidence may have yielded a different picture.

Originality/value

– This is the first paper reflecting on developments in strategic relations between primary and social care from researchers involved with two longitudinal investigations of the early development of PCG/Ts (1999-2002) and CCGs (2011-ongoing).

Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency

BACKGROUND

In recent years joint commissioning has assumed an important place in the policy and practice of English health and social care. Yet, despite much being claimed for this way of working there is a lack of evidence to demonstrate the outcomes of joint commissioning. This paper examines the types of impacts that have been claimed for joint commissioning within the literature.

METHOD

The paper reviews the extant literature concerning joint commissioning employing an interpretive schema to examine the different meanings afforded to this concept. The paper reviews over 100 documents that discuss joint commissioning, adopting an interpretive approach which sought to identify a series of discourses, each of which view the processes and outcomes of joint commissioning differently.

RESULTS

This paper finds that although much has been written about joint commissioning there is little evidence to link it to changes in outcomes. Much of the evidence base focuses on the processes of joint commissioning and few studies have systematically studied the outcomes of this way of working. Further, there does not appear to be one single definition of joint commissioning and it is used in a variety of different ways across health and social care. The paper identifies three dominant discourses of joint commissioning - prevention, empowerment and efficiency. Each of these offers a different way of seeing joint commissioning and suggests that it should achieve different aims.

CONCLUSIONS

There is a lack of clarity not only in terms of what joint commissioning has been demonstrated to achieve but even in terms of what it should achieve. Joint commissioning is far from a clear concept with a number of different potential meanings. Although this ambiguity can be helpful in some ways in the sense that it can bring together disparate groups, for example, if joint commissioning is to be delivered at a local level then more specificity may be required in terms of what they are being asked to deliver.

Modernising social care services for older people: scoping the United Kingdom evidence base

In common with other developed countries at the end of the 20th century, modernising public services was a priority of the United Kingdom (UK) Labour administration after its election in 1997. The modernisation reforms in health and social care exemplified their approach to public policy. The authors were commissioned to examine the evidence base for the modernisation of social care services for older people, and for this purpose conducted a systematic review of the relevant peer-reviewed UK research literature published from 1990 to 2001. Publications that reported descriptive, analytical, evaluative, quantitative and qualitative studies were identified and critically appraised under six key themes of modernisation: integration, independence, consistency, support for carers, meeting individuals' needs, and the workforce. This paper lists the principal features of each study, provides an overview of the literature, and presents substantive findings relating to three of the modernisation themes (integration, independence and individuals' needs). The account provides a systematic portrayal both of the state of social care for older people prior to the modernisation process and of the relative strengths and weaknesses of the evidence base. It suggests that, for evidence-based practice and policy to become a reality in social care for older people, there is a general need for higher quality studies in this area.

Networks and social capital: a relational approach to primary healthcare reform

Collaboration among health care providers and across systems is proposed as a strategy to improve health care delivery the world over. Over the past two decades, health care providers have been encouraged to work in partnership and build interdisciplinary teams. More recently, the notion of networks has entered this discourse but the lack of consensus and understanding about what is meant by adopting a network approach in health services limits its use. Also crucial to this discussion is the work of distinguishing the nature and extent of the impact of social relationships – generally referred to as social capital. In this paper, we review the rationale for collaboration in health care systems; provide an overview and synthesis of key concepts; dispel some common misconceptions of networks; and apply the theory to an example of primary healthcare network reform in Alberta (Canada). Our central thesis is that a relational approach to systems change, one based on a synthesis of network theory and social capital can provide the fodation for a multi-focal approach to primary healthcare reform. Action strategies are recommended to move from an awareness of 'networks' to fully translating knowledge from existing theory to guide planning and practice innovations. Decision-makers are encouraged to consider a multi-focal approach that effectively incorporates a network and social capital approach in planning and evaluating primary healthcare reform.

Evaluating partnership working: lessons for palliative care

Partnership working in palliative care is being increasingly promoted as the solution to poorly coordinated health and social care services. A key example is the UK National Institute for Clinical Excellence (NICE) guidance on supportive and palliative care. However, partnerships have costs in negotiating, developing and maintaining working relationships and translating these into successful outcomes, so may not always be the best or most effective method of service improvement. This article explores structural, procedural, financial, professional and legitimacy barriers to partnership working. We conclude that these five barriers could be sufficient to destroy emerging partnerships. Nowhere in the NICE guidance on supportive and palliative care are such barriers acknowledged. We suggest that current and projected palliative care partnerships should be critically evaluated against both process and outcome success criteria. Such evaluations must be integral to partnerships, to learn about what makes an effective palliative care partnership, and what affects partnerships have on patient care and outcomes. Partnerships may not be the panacea for issues of fragmentation, and should not be the only solution considered. Lessons should be learnt from the UK's promulgation of partnerships to ensure that these are used appropriately and only where patient benefit can be anticipated.

National evaluation of NHS genetics service investments: emerging issues from the cancer genetics pilots

In seeking to fulfil the ambition of the 2003 genetics white paper, Our Inheritance, Our Future, to 'mainstream' genetic knowledge and practices, the Department of Health provided start-up funding for pilot services in various clinical areas. These included seven cancer genetics projects, co-funded with Macmillan Cancer Support. To help to understand the challenges encountered by such an attempt at reconfiguring the organization and delivery of services in this field, a programme-level evaluation of the genetics projects was commissioned to consider the organizational issues faced. Using a qualitative approach, this research has involved comparative case-study work in 11 of the pilot sites, including four of the seven cancer genetics pilots. In this paper, the researchers present early findings from their work, focusing in particular on the cancer genetics pilots. They consider some of the factors that have influenced how the pilots have sought to address pre-existing sector, organizational and professional boundaries to these new ways of working. The article examines the relationship between these factors and the extent to which pilots have succeeded in setting up boundary-spanning services, dealing with human-resource issues and creating sustainable, 'mainstreamed' provision which attracts ongoing funding in a volatile National Health Service commissioning environment where funding priorities do not always favour preventive, risk-assessment services.

Cross-boundary working: a generic worker for older people in the community

The care of older people often crosses the boundaries of health and social care. The new role of a health and social care trained generic worker was developed to provide comprehensive care for older people living at home. The role is a cross between a nursing auxiliary, health care assistant and a community support worker. The evaluation of the one-year pilot project demonstrated that clients were very satisfied with the care they received, particularly the emotional aspects of care. A high proportion of the generic workers time was spent listening and responding to their clients' mental health needs, and providing comfort and emotional support. Having been trained by local health professionals, the generic workers felt valued and respected, better able to communicate with their health colleagues, and therefore able to provide holistic care to their clients.

Breaking down barriers: integrating health and care services for older people in England

Like many other post-industrial societies, England is facing demographic and political pressures to reduce the fragmentation of services for older people. Moreover, current government policies emphasise collaboration and 'partnership', particularly between health and social care services. Recently, two new policy initiatives have enabled the full integration of services to take place, involving formerly separate health and social care organisations-between family doctors (general practitioners) and community health services, and between health and social services organisations. Both initiatives also allow the pooling of previously separate funding streams. This paper presents findings from evaluations of these two initiatives. Drawing on this evidence, the paper concludes that structural integration can transform preoccupations over narrow sectoral responsibilities and boundaries to a 'whole systems' paradigm of service planning and delivery. However, major internal barriers to integration may remain: these include professional domains and identities, and differential power relationships between newly integrated services and professionals. Moreover, the success of these new horizontal, inter-organisational arrangements is profoundly influenced by the wider policy environment and by vertical relationships with national government. Together, these pressures exclude the voices of older people, and therefore call into question whether the considerable organisational upheaval of service integration will be able to deliver the changes valued by older people themselves.

Social services representation in Primary Care Groups and Trusts

Against a rapidly changing policy backdrop, health providers and social services departments in England are attempting to develop partnerships in order to effectively provide services. Relations between health and social care organisations have long been recognised as being problematic, in terms of historically poor relationships between GPs and social services departments and the non-coterminous natures of many organisational boundaries. The development of Primary Care Groups and Trusts has provided an opportunity to try to overcome some of these problems. This paper draws on a national survey of a sample of Primary Care Groups/Trusts and associated in-depth case studies to describe the roles of the social services representatives on Primary Care Group Boards/Trust Executive Committees and discusses the extent to which closer collaboration in the development of services is occurring and its potential for development in the future. It highlights the importance of greater organisational stability and the need for time to form effective partnership arrangements in the future.

Developing the effectiveness of primary care organisations in the UK National Health Service

This paper aims to explore the early experiences of a new primary care organisation in the NHS. It reports the findings of a longitudinal qualitative case study of one primary care group in its first year of operation. It concludes and makes recommendations in four key areas relevant to the development of the primary care group: the experiences of individuals and their readiness for change; clarity and consensus about roles and responsibilities in the new organisation; the process of change, and the impact of culture/power structures; and developing relationships with internal and external stakeholders.

Evaluation of the effect of co-financing on collaboration between health care, social services and social insurance in Sweden

In this paper, we present an ongoing research project aimed to determine the impact of co-financing on collaboration around patients with musculoskeletal disorders. A trial legislation that allows the social insurance, social services and health care services to unite in co-financing under joint political steering has been tested in different areas in Sweden. In a series of studies, we compare collaboration processes and health outcome for patients with musculoskeletal disorders between health centres with co-financing projects and control health centres without co-financing projects. In this paper the studies are described and some preliminary results are discussed.

Primary care budget holding in the United Kingdom National Health Service: learning from a decade of health service reform

1. The United Kingdom National Health Service (NHS) has experienced 10 years of primary care budget holding in a variety of forms. 2. Half of all general practitioners had joined the GP fundholding scheme by 1997, and many others had joined broader GP commissioning groups, but fundholders controlled only about 20% of the budget for hospital and community health services. 3. Research on fundholding and commissioning groups suggests that delegation of budgets produced some gains in the range and effectiveness of services, but also had significant management costs and inequities. 4. From 1999, all primary care professionals joined Primary Care Groups, which are now becoming Primary Care Trusts (PCTs). PCTs will control three-quarters of the healthcare budget and provide all primary and community services as well as commissioning hospital care. 5. Control of a unified healthcare budget presents opportunities to improve quality, increase integration of services, reduce inequities and improve health. However, PCTs are threatened by a growing gap between capacity and expectations, and by continuing tension between devolution of power and increasingly prescriptive management by central government.