The organisations involved

The first and most fundamental question is which services are integrating. This is likely to be driven as much by practicalities and politics as by preferences or perceived optimal models. Many of these decisions are likely to be taken ‘above’ front-line clinicians and even relatively senior managers, sitting with trust boards, local authorities and commissioning groups. Nevertheless, it is helpful to map this out: it aids understanding of the local model and interpreting data from others (at present, all are likely to describe themselves as ‘integrated/integrating’ systems but be quite different). It is also worth considering the power of shop floor clinicians agreeing on change: if this occurs it is a compelling case for more senior levels of management.

Table 1 gives an overview of the services that might be included. One might consider this across several levels: from primary care through various secondary and tertiary healthcare services, to the local authority and the third sector. Each of these will have numerous subdivisions, some divided by demographic group (e.g. children's or older persons’ services), some by geographical location and some by function (e.g. psychosis or frailty pathways). This can also occur to different degrees: from merged teams with single management, through merged boards and finances, to co-located but separate services or agreements/memoranda on closer working.

TABLE 1

An overview of the areas that should be considered by integrating services

Source: adapted from Tracy et al (Reference Tracy, Hanson and Brown2019).

There are many permutations of this: for example, a National Health Service (NHS) trust and local authority might keep their own boards and structures but agree to pool service and team management; they might harmonise human resources processes, but keep finances separate, and so forth. In terms of the NHS and local authority, national challenges include the facts that they use separate email and IT systems; in the short term, workarounds can be found but at present these systems cannot be merged, inevitably leading to some duplication.

The specific teams: closer working or merging?

Clinicians and managers are most likely to get involved at a more granular level about which and how specific teams or services within integrating organisations might better work together in novel ways. As an example, let us consider this within the context of a typical mental health trust. At the highest level, one might deliberate major functional groupings within a trust – child and adolescent mental health services (CAMHS), older persons’ mental health (OPMH), intellectual disability, adult mental health (AMH), forensic mental health – and those that might be divided geographically, for example by borough or district. There are thus two broad approaches one might take: integrating functional services (such as CAMHS with children's social care) and integrating geographical ones that specify merges by location. There is a general move in the UK back towards geographical models, in part to align with integrated structures and local authority boundaries, but clearly there are many variations that this might take.

One might make a cogent argument, for example, to include CAMHS, AMH and OPMH – covering the lifespan and families – in a geographical footprint. However, historical and training boundaries mean that such profound merge is unlikely to occur widely in initial iterations of integrated care. The exemplar organisation discussed in this article has adult and older people's mental health, secondary care physical health and adult social care within a geographical boundary of a London borough. Fig. 1 maps out the integrated teams in this model; it might be informative to contrast these with the types, numbers and relationships of parallel services where you work.

FIG 1

The local care network (LCN), the primary new integrated team in a south-east London borough, which is geographically constituted of three such teams that each map onto a corresponding general practice (GP) primary care network (PCN). This offers a considerably wider range of services and professionals than a typical community mental health team (CMHT) and has fewer interfaces than many such services. In this model, ‘secondary mental health’ includes general psychosis and non-psychosis care, with the exception of early intervention and rehabilitation, which remain separate. The LCN has a single management team, meaning that there are no internal referrals. There is a matrix management structure, whereby the LCN operational manager and quality lead may be from any professional group, but each profession has a professional lead for development and training. Most referrals come via a single point of contact that will take all mental health, community physical health and social care referrals within the borough. Note that in-patient and crisis services also sit outside the LCNs and work across the three LCNs.

These questions continue at a more granular level. For example, let us just consider adult mental health in a given district or borough. In the UK today, it is typically divided into a large number of ‘functional’ teams: home treatment, early intervention, rehabilitation psychiatry, in-patient services and community teams that have most commonly in recent years been split into ‘psychosis’ and ‘non-psychosis’ aspects. For some, substance use and intellectual disability might also form part of this, and there will be links to specialist and tertiary services, for example eating disorder services. The question arises as to how these teams might work in a more integrated service with physical health and the local authority. Again, there will be a spectrum of possibilities, from staying structurally similar but working more closely with other teams and services through to physical merging. The general push of integration will be towards fewer teams and more ‘local footprint-based’ care. In some ways this perhaps models the more old-fashioned generic community mental health team (CMHT) – the difference being presumed enhanced working with the local authority, secondary care physical health and primary care.

The opportunities and problems of integration are exemplified by considering the two ends of the psychosis treatment spectrum: early intervention and rehabilitation services. On the one hand, the populations they serve have much to gain from a novel community team with enhanced social care and physical health input; on the other, the reason these evolved as distinct in the first place was an awareness that these patients risked getting lost in a wider, larger system. There is no single correct answer as to which teams might merge, and we are again confronted by the lack of evidence or guidance.

Relationships: looking internally – ‘lanyards and car parking’

What we learned:

• • the changes that integrated care necessitate are enormous and can be very distressing for staff: people may fear redundancies, loss of role and expertise, and being overwhelmed by increases in quantity and new types of work

• • staff will appreciate the concept and values of integrated care, but will also have very practical implementation concerns that must be addressed early – from needing different commutes to work to problems with parking and desk-space

• • integrating health and social care presents unique cultural challenges: social care staff can feel a junior partner to, and less valued by, healthcare, and healthcare staff may have strong allegiances to the NHS that can feel threatened.

What you might consider:

• • conversations with staff can never start early enough or be frequent enough: engage as soon as possible, including being honest about what is known and not known

• • management should lead by example, with a cohesive leadership team from all staff backgrounds and using these senior staff as exemplars of integration

• • engage those who use services and their carers

• • have a good communication strategy.

From the conceptual to the practical

It has been our experience that one the greatest challenges has been engaging the hearts and minds of staff working in proposed novel services. For obvious reasons, integration appeals to service users (see the section ‘Matrix management and culture’ below regarding terminology), their carers and relatives, and the public, none of whom would design the professional siloed services we have today. The potential gains of reduced bureaucracy, avoiding delays in referral and repetition of one's story, and more joined-up care and a better experience are self-evident (whether or not delivered in practice). For managers, those factors equally ring true, added to by the allure of being able to deliver services on often static or reducing budgets through better efficiency.

Front-line staff will appreciate and understand these factors – we have yet to meet anyone conceptually against ‘more integrated care’. However, a core tension can be a sense that the oft-mentioned demographic, workforce and financial stresses on health and social care are what matters and are leading service redesign, rather than a philosophical drive to provide better care. Of course, these are not exclusive concepts, but there is the danger with integrated services that it can feel like ‘the money’ (or lack of it) is driving everything.

Staff will, understandably, immediately identify the practical challenges they will face in delivering integrated services. These factors are multifaceted and real, and need to be inquired about and addressed as early as possible. Conceptually ‘simple’ but practically highly important factors rapidly emerge, such as the upheaval of physically changing site and determining car parking, particularly for staff who do home visits. Discussions should involve potential real-world issues such as: school runs, traffic congestion, and personal life commitments around the geography of our home and work.

All existing teams have defined roles, from home treatment through to early intervention. Staff will recognise and value the unique inputs their teams provide and will be concerned that this might be lost in bigger systems. Merging teams, beyond the physicality of any geographical move, challenges staff identities and this is often not welcomed. A common, understandable, refrain went along the lines of ‘integration is a good idea locally but won't work for my team’.

It has been our experience that although fear that specialism will be lost in a bigger team was common and one of the biggest concerns, this has not been borne out in practice. However, initial feedback from staff about this risk was so powerful that it was explicitly considered from the start and clear lines of clinical accountability and opportunities for interaction with appropriate clinical groups were carefully included in the design.

Multi-skilled working or overworked generic jobs?

All staff will recognise the unwelcomed duplication, bureaucracy and delays that come from existing models and will favour their reduction. Equally, all will be in favour of enhancing their own training, skill mix and services for those with whom they work. New integrated services might assist with all these points, but they also raise clear and understandable challenges.

Some tasks might be relatively universal, such as documenting the core features of ‘presenting complaints’ and difficulties, and it would seem reasonable that most staff could begin to document these, including a range of mental health, physical health and social care needs. Common electronic assessment forms afford the opportunity to capture this information, reducing time and effort for both service users and staff. However, anyone who has tried to design a form to capture everyone's (service users’, carers’ and professionals’) concerns and areas of importance will realise how quickly and burdensome these can grow.

It is perhaps a less explored aspect of health and social care that the barriers against which we all complain undoubtedly act, even if unintentionally, to reduce or manage demand. Integrated reduced bureaucracy also means fewer barriers to accessing already overworked services. This will apply for both ‘true’ need (e.g. in part 1 we noted how only a minority with a mental illness received any care at all; Tracy Reference Tracy, Holloway and Hanson2020a) and ‘false’ or inappropriate need (e.g. a district nurse picks up a possible case of mild depression in someone whose wound dressing they were changing and books the person into a consultant psychiatry clinic). In either case, the integrated system might be perceived as ‘creating’ more work, which will inevitably concern many staff. There are arguments that such systems should tackle need more appropriately at an earlier stage and thus actually reduce workloads, but the general lack of evidence at this time is problematic.

Integrated services offer staff the opportunity to learn new and even very novel skills from other professional groups with whom they might otherwise not ordinarily interact. This might be through observational learning, joint working, shared teaching or clinical discussion, and more formal education and skills development. We have found this to be very fruitful, for example in our south-east London service we started with areas common to most professionals, such as substance use or safeguarding work.

Conversely, ‘multi-skilled working’ might feel like ‘doing someone else's job’ (which perhaps was lost through ‘financial efficiencies’). Most of us have specialist skills and we might worry about losing them through less exposure in more generic services, and indeed that such services might get cut. Trainees’ competency development and continuous professional development of established clinicians will need to find ways to work with this. There are no fundamental reasons this cannot occur and the Royal College of Psychiatrists has issued largely supportive guidance on integrated care systems (Royal College of Psychiatrists 2019): it will be incumbent on local trainees, trainers, deaneries and the RCPsych to work together to ensure that this happens and indeed taps into new development opportunities.

A potentially wider range of service users within an integrated team risks staff being anxious about missing important factors or dealing with emergencies outside of their skill set: for example, those from social care managing someone feeling suicidal, or mental health staff documenting intermittent problems with respiration. Of course, this can happen with non-integrated models and without the resource of the wider groups of professionals. Clear local systems to triage such instances are required.

Matrix management and culture

Integrated teams will contain, by design, wider groups of professionals. However, that might mean that there are relatively fewer of those with whom one is used to working, and for many staff direct line management might now be from someone of a different professional background. In principle, this is not organisationally unreasonable, but it may bring up the question of ‘what does profession X know about my work?’. Our model is of ‘matrix management’, wherein ‘operational’ management of how teams run can be via any appropriately skilled and qualified staff, but ‘professional’ management that considers career training and development must be done by someone of the same background.

The cultural issue of ‘identity’ is also critical and can be quite complex. In our experience, social care can often feel a ‘junior partner’, with healthcare driving and leading changes (and indeed this is correct insofar as the NHS Long Term Plan is the driver). Recognition needs to be made that we are not necessarily ‘all NHS’ anymore. Conversely, in one of our integrating organisations, as we were merging with adult social care, staff lanyards were changed to remove the NHS lozenge to foster cohesion. Yet so many staff in healthcare identify passionately with being part of the NHS and reacted strongly against this move. Within the NHS side, both physical and mental health staff can feel that the ‘other’ is leading or receiving emphasis: this is typically not the case, but the perceptions matter and need to be explored and opened up.

Language matters and is often used quite differently across organisations. Social care will correctly remind us that they do not see ‘patients’ – in keeping with BJPsych Advances journal style guidelines and RCPsych guidance on the topic, we have generally kept to that phrase in these three articles, but integrated systems will raise interesting variation in perspectives and thinking on this and related issues. More subtle differences can arise, resulting in often profound differences in understanding even when using the same words. One seemingly simple example we found, which had significant impact on an individual's care until the difference was realised, was how differently health and social care staff understood and had been using the phrase ‘trauma-informed care’.

Nevertheless, it has been the experience of several of us that one of the most profound but least recognised or discussed gains of integration is also cultural. Our training gives us different, and often complementary, views and perspectives, as well as variation in factual knowledge or skill sets. We have found these to offer very significant gains. At a very elemental level, social care brings a valued strengths-based enablement approach and philosophy that works from the perspective of getting people to live their lives as independently as possible and focusing on their strengths. Conversely, many in social care have valued the evidence-based evaluative approach brought by healthcare.

Primary care

Most existing teams and services have relationships with primary care, whether or not they accept direct referrals. In the integrated landscape, individual teams/services might retain direct access/referral but might introduce single assessment hubs covering a wider range of services. For example, in the described model, an overarching single point of contact has been established that allows primary care access to all secondary care mental and physical health services as well as adult social care (Fig. 1). A challenge in this model has been that once open to any part of the integrated care system, it might seem reasonable that ‘all relevant problems’ are thereafter dealt with internally. Depression is perhaps a good case in point: the local system noted is such that, as per National Institute for Health and Care Excellence guidelines, mild to moderate depression is initially dealt with in primary care, even if the individual is receiving care from the local care network (LCN) for other health and social care reasons. That opens up the potentially counterintuitive situation for a service user and general practitioner (GP) that someone being seen in an integrated team setting for their physical health might be asked to see their GP about their low mood, despite that team already having a full complement of mental health professionals. An analogy for the individual and GP would be that if one was admitted to an acute general hospital with a specific illness, it would not necessarily follow that any other identified healthcare problem would be managed by other in-patient teams.

Primary care practices are undergoing their own changes, moving into primary care networks (PCNs, explained in part 2; Tracy Reference Tracy, Holloway and Hanson2020b) of practices covering ‘natural populations’ of about 30 000. The aim is to balance personalised care with some scale up of facilities. The PCNs will face analogous issues to the integrated teams in terms of what they might wish to manage internally in a single PCN (covering several practices) or whether they might wish to share resources for more complex issues, for example frailty pathways, across a group of PCNs in a local district or region.

The increased scale and scope of PCNs offers new ways of working in primary care and new potentials for interfacing with secondary care. There is a national trend towards greater psychosocial and preventive work, for example with more community pharmacists and ‘social prescribing’. Some of this will augment and should link well with secondary care, but one can also envisage overlap that might cause confusion. Equally, a PCN that clusters several primary care practices offers a similar population scale to that typically seen by a community mental health team. This can offer a more efficient interface for both sides. In the described south-east London service, the PCNs map onto the LCNs in three borough-divided footprints (there is actually a fourth PCN that traverses the LCNs, but for management purposes those practices fit into the three LCN:PCN governance/interface meetings). This affords them the opportunity for regular interface meetings that explore and rectify governance or systems issues, as well as ‘integrated case management’ (ICM) meetings where patients with complex multiple needs are reviewed and optimal care decided. However, it is important to note that PCNs are not obligated to map onto the boundaries of mental health integrated teams and mismatches risk interface difficulties.

The local authority

One primary drive of integration is to enhance the relationship with the local authority. As with healthcare, local authorities divide into ‘directorates’, for example, children's services, adult services, public health, substance use services and so forth. Local authorities face different targets, at least at present, from those in healthcare, for example the Adult Social Care Outcomes Framework (ASCOF).

The local authority, secondary care and commissioners, via the CCG, traditionally come together to review provided services. The general merger and expansion of CCGs to map onto an ICS means that in many instances this interface, as it has historically existed, will be lost. This is a concern to many, not least as such relationships have often been built up over many years and the new enlarged ICSs will have a larger perspective that might miss or be in conflict with the smaller population covered by the local authority. New ‘-place-based boards’ will replace these relationships, but they have not been tested in practice. In the described exemplar site, the local authority and secondary care functionally merged, but this is a less common model at this time.

The third-sector and external agencies

Opportunities exist for new ways of working with external and third-sector agencies. A principle of integrated systems is place-based care – see part 2 (Tracy Reference Tracy, Holloway and Hanson2020b) – and being part of local communities. Although this is currently less explored in the first iteration of services, there are obvious novel opportunities to work with resources such as cultural, sporting and faith-based organisations.

The integrated care system

Integrated care systems (ICSs) were described in part 2 (Tracy Reference Tracy, Holloway and Hanson2020b). It is intended that ICSs will allow long-term planning (and commissioning via the matched CCG) over a considerable geography and demography, aiming to minimise duplication and inefficiencies. However, there are numerous overlaps that will bring about inherent tensions that need to be resolved: for example between different NHS trusts, NHS England and NHS Improvement, local integrated care partnerships and so forth.

The science of implementation

The science of implementing change is large and varied. A full description of both theoretical and empirical aspects is beyond the remit of this article; for those interested in more detail we refer to works such Greenhalgh (Reference Greenhalgh2017). Briefly, literature often divides obstacles and facilitators to overcoming barriers at several stages – from initiating through to maintaining (Table 2) – and at different levels: organisational, team and leadership.

TABLE 2

Characteristics of innovations

Source: adapted from Grol & Wensing (Reference Grol and Wensing2004).

Measurement: what to weigh?

Three major issues present themselves when considering how one might measure success and failure in an integrated service. First, integrated models, as we have seen, will vary widely and thus cross-comparison between them is difficult. Second, organisations often lack ‘before’ data with which to make subsequent comparisons. Third, in a complex changing system that has numerous inputs, many coming from outside of the integrating system, ascribing causality to the new model can be very difficult, particularly in the absence of a ‘control model’ for comparison. These issues should not preclude integrating organisations from trying to measure change: the above-mentioned lack of evidence on the topic makes it ever more important for early sharing of ‘learning from doing’. Describing one's integration model is a key first step, as this will also allow other organisations to make fairer comparisons with their own. Is it geographically or ‘functionally’ based, which age groups and population types does it serve, which organisations and teams are involved, and how closely aligned or merged are they? A typography of integration has not yet been established to allow a universally agreed description of these factors, although it is likely to emerge in one form or another in the coming years.