Scottish Government

Chapter 2: What is Integrated Care?

Integrated care is an approach that aims to combine and co-ordinate all the services required to meet the assessed needs of the individual.

It requires:

• treatment, care and support to be person-centred, inclusive and holistic to address the wide ranging needs of drug and alcohol users;
• the service response to be needs-led and not limited by organisational or administrative practices; and
• collaborative working between agencies and service providers at each stage in the progress of the individual in treatment, from initial assessment onwards.

The Rationale: Why is Integrated Care Important?

People who have drug or alcohol misuse problems will, in many cases, have a range of other difficulties in their lives including problems with housing, family relationships, employment, offending behaviour and debt. This means that a wide range of interventions and a range of organisations will need to be involved to assist any individual with substance misuse problems.

Service users (and indeed providers) often feel that there is no communication between the various agencies leading to frustration and disappointment. Service providers may not deliver an effective service because they do not have access to all the relevant information about an individual nor an awareness of the roles of other agencies who could potentially be involved in their care.

Service users also commonly feel that support is weighted towards the beginning of the recovery process, jeopardising this process in the long-term. The EIUMoving On report highlighted that clients who have moved on to employment needed on-going support to cope with the transition in their lives.

An integrated care approach founded on co-operation and collaboration between all relevant providers will have a number of benefits for individual service users. It should:

• Promote early assessment and intervention: ensuring that services are accessible and appropriate to the service user's needs.
• Remove barriers to progressing towards recovery: supporting the service user to identify and achieve their own goals whilst acknowledging their own beliefs and culture.
• Provide consistent, co-ordinated and comprehensive care: ensuring that all care providers are working towards a shared aim and minimising unnecessary duplication of activity.
• Ensure a comprehensive and timely response: making sure that all the needs of the service user, physical, psychological and social, are considered and addressed appropriately.

Goals of Integrated Care

There are a number of different treatment philosophies and approaches in the substance misuse field, reflecting the different needs and priorities of both service users and providers. These approaches have their own intended outcomes. However, it is important to set out the overarching aim of integrated care while accounting for these different philosophies.

The overarching aim of integrated care is to support drug or alcohol users to overcome their drug or alcohol problem and their associated health and social difficulties by providing effective, co-ordinated and timely treatment and care.

Which Service Providers are Involved?

Throughout an individual's recovery they may require different interventions which will usually involve contact with a number of different service providers The different interventions and the different service providers should be regarded as being of equal importance within the context of developing a person-centred approach to care. The order with which a person accesses services and interventions should be based on the prioritisation that occurs after the initial comprehensive assessment. This assessment process and resulting prioritisation is ongoing and therefore subject to review and change.

Which Partner Agencies Need to Work Together?

Planning and delivering an integrated care service for drug or alcohol users will involve ADATs and all associated agencies and organisations potentially involved in the care of drug or alcohol users. It will require communication, co-ordination and co-operation. This involves recognising the role of each agency and developing effective partnership working. No single agency can effectively meet the diverse needs of people affected by substance misuse.

Partnership working is not new. Many organisations have been working in partnership for many years. However, time, careful thought and on-going effort are required to build and maintain effective partnerships. In many ways, ineffective partnerships are easier to characterise. They are often partnerships in which one agency dominates decision making and planning; there is often minimal community and user involvement; aims and objectives are not clarified; and there is little accountability or trust. It is harder to characterise a successful partnership. However, the literature on good partnership working suggests that the ingredients of a successful partnership include having:

• clear identity and role for the partnership
• clear identity and role for each partner agency in the planning, design and delivery of services
• shared short and long term aims and objectives
• sufficient time and resource dedicated to partnership building
• adequate training for all members, including community and user representatives
• a supportive atmosphere where discussion and new ideas are welcome
• clear and supportive leadership
• an atmosphere where organisational and cultural barriers can be explored

The National Treatment Agency for Substance Misuse ( NTA) Briefing on Working in Partnership (2005) looks at the terms used to describe partnership working in the drugs field and the various types of partnership initiatives. It also outlines the benefits of partnership working, factors that influence the success of partnership working and policy development issues.

The NTA guidance identifies a number of common barriers to partnership working:

• Culture clashes, ideological differences and rivalry between organisations
• Difficulty maintaining continuity of care when there are multiple agencies involved
• Difficulties in establishing accountability arrangements when multiple organisations are involved
• Tensions between a health perspective and a criminal justice perspective

The full briefing, including useful web links and references can be downloaded at http://www.nta.nhs.uk/publications/documents/nta_working_in_partnership_2005_ddsp8.pdf

To achieve integrated care, partnerships will need to be established at both strategic and operational level. The ADAT will have the lead responsibility for co-ordinating the planning and delivery of services in an area. The development of joint resourcing and joint management in local areas through Joint Future provides both an impetus and supporting structures.

At strategic level, the ADAT and partners should agree:

• the aims and objectives of an integrated service
• the range of services that could or should be engaged
• the way in which the views and experiences of service users and carers can be represented and addressed when planning, commissioning and reviewing services
• the commissioning and management arrangements, including joint resourcing
• the arrangements for sharing information
• the arrangements for multi-agency training to promote mutual understanding of roles
• monitoring and evaluation arrangements

At operational level, service providers should agree:

• common or core assessment procedures and datasets
• arrangements for ensuring that service users and carers are fully engaged as partners in the planning, delivery and review of an individual's care
• systems and protocols for sharing information
• systems and protocols for referral and joint working

Good practice guidance on involving service users in the planning and review of service provision can be viewed at http://www.scotland.gov.uk/Resource/Doc/202522/0054004.pdf

Achieving integrated care will depend upon having effective mechanisms to communicate and exchange ideas between strategic and operational levels. Strategy needs to be developed through dialogue among those who understand how services are currently delivered, and what could undermine any process of change. Success will depend upon service providers having a sense of ownership and understanding of both the principles that underpin integrated care and the changes in practice required to deliver them.

An example of integrated working at strategic and operational levels is the development of Community Justice Authorities ( CJAs).

'Community Justice Authorities will be responsible for distributing funding for criminal justice social work and monitoring and reporting on the effectiveness of joint working between local agencies to tackle re-offending.'

The Criminal Justice Plan, published in December 2004, set out proposals for reducing re-offending by improving the management of offenders and ensuring that all organisations that provide offenders' services - local authorities and the Scottish Prison Service ( SPS) - work more closely and effectively together.

Once established, CJAs will receive the community component of criminal justice funding and be responsible for ensuring this is used effectively across their area to tackle re-offending and improve offender management. They will also be required to work in partnership with a range of partners including police forces within the CJA, NHS Boards, voluntary organisations in receipt of funding from local authorities or SPS for their work with offenders and/or their families, Scottish Court Service, Crown Office and Procurator Fiscal Service and Victim Support Scotland.'

In December 2007 the Scottish Government published Better Health, Better Care Action Plan which makes reference to current cross-cutting working; the new national drugs

strategy to support a framework to deliver drug treatment services; continuity of care during the transition between community and prisons and community; SSA and electronic sharing of information.

The full document can be viewed at http://www.scotland.gov.uk/Resource/Doc/206458/0054871.pdf

Action Points: What is Integrated Care?

The tables below sets out a number of questions that service planners and commissioners should consider in order to ensure that the principles of integrated care are being met.