The main activity that underpins integrated care for older people at the individual level is the co-ordination of services at a locality or a specialist network level. Essentially, this involves co-ordinating and managing activities between teams and different providers. This, in turn, needs to be supported by planning services for the whole older population in an area: the ‘whole-system level’ (Edwards and Miller 2003). This chapter is about planning across the whole system of local services, across different statutory, private and non-governmental sectors, to support the delivery of integrated care.
Understanding the connections between services and how different services impact on one other is crucial for meeting the complex and diverse needs of older people. This chapter describes some models and approaches to undertaking whole-systems planning and the key steps for planning and implementing change. Strategic planning is more likely to be effective in Beveridge-type national health systems than in the more Bismarckian and market-driven systems, in which there is less top-down control. Nevertheless, the concepts in this chapter will provide valuable insights for such systems.
Strategic planning is not concerned with the operational management of services. Instead, it is about key stakeholders from the statutory, non-governmental, private and community sectors working together to achieve a shared understanding of their local service system in order to redesign and improve the way it operates. This addresses the balance of services, the connections between health, social care, housing, transport and other community services, and the interdependence of services. Strategic planning takes local resources – including financial resources, supply and demand factors – into account, along with national policy, trends and other influences.
Although the context and drivers for planning are different in each country, the process of working together to understand how the local system operates is in itself important, and goes well beyond the production of plans on paper. This is not a static or one-off process but involves continual review, as plans are implemented and changes take place. Managing change and turning broad strategic plans into business plans will require a range of influencing skills and management approaches that are not covered in detail in this chapter.
Strategic planning seeks to achieve a balanced system of care that offers a comprehensive and co-ordinated range of services. These include services that:
This approach has been described as a ‘virtuous circle’ of services, where action in one part of the circle can have an impact at a different point – so, for example, prevention services to support older people to stay well at home, plus rehabilitation and other flexible services, can improve the working of the whole system of services, preventing unnecessary admissions to hospital or residential care (Carrier 2002).
The aim of strategic planning is to obtain a shared picture of the whole service system in order to plan and deliver capacity in the system, to offer older people choice, quality services and access to care – sometimes referred to as ‘the right services, at the right time, in the right place’.
Organisations and agencies seek as much control as possible over the way they operate. This enables them to be less crisis-driven, understand their interdependencies with other organisations, and to be clear about their contribution and what to expect from others. Integrated strategic planning also offers opportunities to focus resources on joint priorities.
Adapted from Department of Health (2003b)
Various tools are available to support mapping and planning services at macro and micro levels. Some support widescale redesign of services over a geographical, local government or health area, while others support the redesign of services at an operational level, to improve processes and the experience of older people. This section primarily focuses on the strategic level and achieving a full spectrum of services that acknowledge their interdependency and how they fit together. (For more information on mapping services and patient journeys at operational levels, see Chapter 5.)
The following tools have been developed using experience from the field. They offer guidelines, checklists and examples of good practice for those aiming to develop more integrated approaches to planning:
The following brief descriptions of each of these tools illustrate the range of materials and approaches that have been published. No critique is offered, but the reader may wish to follow up the references provided at the end of each description for more detailed information.
This approach takes the needs of older people as its starting point. Working with local stakeholders in workshops, it defines and populates a set of dependency groups. The resource consequences of different ways of providing care for these groups can be explored using a computer model. This enables volume, costs and types of services to be calculated, as well as indicating the potential impacts for the different organisations involved. (Forte et al 2002)
Also known as ‘the whole municipality working together for older people’, this approach offers targets and action models for local authorities to support the development of their service structure. The models are based on local needs and resources, and are designed to promote participation of clients, relatives and other citizens in setting targets and assessing activities. The collaborative process of planning, monitoring and evaluating the strategy and service development programme is based on the model of the Danish Ministry of Social Affairs, shown in Fig 10 overleaf.
Whole-system events offer one way of engaging all the different stakeholders including older people and their carers. These are events to agree shared values and principles, to develop a common understanding of national policy and local circumstances, map existing services, match services to needs and begin to action plan for change.
Source: Vaarama et al (2001)
Day One began with everyone exploring the patterns of local services that have the potential to deliver or support rehabilitation. Older people brought a different perspective to this exercise, often suggesting rehabilitation opportunities unrecognised by professionals, such as tea dances, swimming clubs and exercise groups. The contribution of the professionals, on the other hand, was often restricted to naming services run or commissioned by the National Health Service or social services.
By identifying what existing services did well and what they did less well, the participants were able to move on to setting possible agendas for change. Thus, in almost every case, people recognised the need to integrate care, through closer partnership working across agency and professional boundaries. Older participants frequently emphasised the lack of rehabilitation opportunities in the community.
Day Two began by getting people to imagine how, in an ideal world, they would like to see rehabilitation opportunities improved in three years’ time, using the ideas generated in earlier sessions. Various themes emerged, including objectives for systems and individuals, ideas for new services or reshaping existing ones, and changes in individual working practices. Groups of participants then selected a theme and developed an action plan for bringing about the desired changes.
Source: Stevenson and Spencer (2002)
A self-audit tool has been developed for managers in health, social care and independent sectors who have responsibilities for ensuring the delivery of a range of non-acute services for older people. The tool, in the form of a workbook, reinforces a whole-systems approach to change, and is designed to help multi-agency groups identify key steps. Questions are posed to managers from all the partner agencies covering the following topics:
Department of Health (2003a)
This resource book provides guidance for commissioners (who plan, secure and monitor services), practitioners and managers to improve discharge planning. It advocates a whole-system approach to tackling hospital discharge. The approach requires commissioners in primary care trusts (statutory bodies responsible for delivering health care to their local population) and local authorities (with responsibilities for social services and other community services) to work together with the independent sector and other stakeholders. It identifies three main areas where integrated whole-systems working underpins the discharge care pathway:
With capacity planning, its aim is to make sure that current capacity is used to its best effect, and that capacity is increased, to avoid the need for hospital admission and to support earlier hospital discharge. Steps to achieve this include starting with a review of pressures in the local health and care system, and agreeing on specific action plans to develop a range of integrated community services, such as:
(Department of Health 2003b)
There are a range of ways to involve older people and carers in planning processes, for example:
The following points are drawn from research and experience in involving older people and carers:
After all the local stakeholders have agreed on the catchment population or boundaries for planning purposes, the ideal scenario is that all the stakeholders in the service system take the following four steps:
Shared principles that are agreed by all the stakeholders are important for assessing any proposed changes. For example, does a new service address the needs of older people from all communities? Do services promote independence? It is also important to have a shared understanding of national policy, trends and other circumstances that might affect local services.
This includes understanding:
The challenge here is to achieve agreement or reach a compromise about priorities when partners have different objectives. Success depends upon a number of factors reflecting the strength of partnerships, the perceived benefits of working together, and power imbalances. The checklist below, and the later section on supporting factors, list a number of key issues that may be helpful for partnership working.
This involves identifying local resources (staffing, property and financial resources) and shortfalls, flexibility of resources and working out how these can be developed, reallocated or redeployed. It also requires all parties to agree a joint action plan that:
In practice, committing to plan together presents considerable challenges for the different players, given competing professional and organisational loyalties. Achieving change will also greatly depend on local decision-making and political processes.
A cross-section of relevant staff at different levels within each organisation, and from across all the partner agencies, need to have input in describing and mapping the current system, as well as planning for change. This is important to understand how the system operates in practice, as well as to achieve ownership for change. Direct input from older people and carers is also crucial for understanding what happens in practice, and for supporting staff in focusing on outcomes for older people, rather than being constrained by professional or organisational ties.
To achieve change, senior executives need to provide encouragement for ‘bottom-up’ or operational-level solutions that can improve services in ways that benefit older people and their carers. They can play a key role in enabling these types of development to take place (or providing incentives) within an agreed framework or vision for services, and in accepting an element of risk-taking. All partner agencies need to agree on what identifies success when evaluating innovatory practice and services.
To realise strategic plans, it is best to appoint special staff who do not have other operational pressures to lead programmes of change or major service reconfigurations. These staff would need specific training in managing change.
Achieving change across a whole system of services may also be supported by identifying professionals, managers, practitioners, local politicians and others in different agencies who will promote and support whole-system approaches and reinforce the benefits on all sides, planning together and implementing change.
All key stakeholders need to be involved in monitoring progress and must work together to agree on:
Any evaluation framework needs to reflect a range of perspectives and dimensions. These should include:
These factors have been used, for example, in the ‘balanced scorecard method’ (Kaplan and Norton 1996).
Strategic planning for integrated care does not entirely depend on top-down, centrally driven planning, but in the absence of good collaborative working it does need incentives, including financial incentives, to promote local joint working. Systems that rely totally on informal processes – particularly between providers only – may have more problems in sharing risks and finding win–win situations. It may be particularly difficult for informal partnerships or networks to deliver when their plans reach the implementation stage, especially if the players are in competition.
Decision-making may also be more difficult and complex where organisations are forming new partnership or network arrangements. These new partnerships may have to concentrate on broad strategy and leave the detailed implementation to smaller collaborative teams, with clear and specific agreements on what, how and who will deliver (Nies 2003). There may also be difficulties where values and cultures clash – for example, where there is a lack of harmony between the values of health care personnel (especially physicians) and the overall goals of a whole-system approach (Åhgren 2003).
Power imbalances, particularly relating to financial clout – for example, between the acute health sector and others, or between commissioners and independent providers – may make it more difficult to achieve planning partnerships and agreement on implementation. Different funding streams for health and social care services, and budgetary pressures, may also impede joint developments and implementation of plans where there are fears of picking up the other partner’s deficit or losing the ability to reallocate resources (Banks 2002).
Strategic planning for integrated care is supported by national policy that provides financial and other incentives to whole-systems approaches and that addresses legal and other barriers. For example, in England, legislative changes have been introduced to allow for the pooling of budgets. National policy can play a key role in setting the broad vision and standards while allowing for local implementation, innovation and autonomy (see Banks 2004).
Leadership at senior and middle levels is crucial in providing a strong local vision of how services should develop. Senior and middle managers must also support activities benefiting older people and the system as a whole. In some instances, this may mean making decisions that may not appear to have short-term benefits to the organisation but are likely to be beneficial in the long run.
The process of working together and collaborating to plan and deliver local strategies for integrated care is supported by:
Åhgren B (2003). ‘Chain of care development in Sweden: Results of a national study’. International Journal for Integrated Care, vol 13. Available at: www.ijic.org.
Banks (2004). Policy Framework for Integrated Care for Older People. London: King’s Fund.
Banks P (2002). Partnerships Under Pressure: A commentary on progress in partnership-working between the NHS and local government. London: King’s Fund.
Blunden R (1999). Terms of Engagement – Engaging older people in the development of community Services. London: King’s Fund.
Carrier J (2002). Integrated Services for Older People: Building a whole system approach in England. London: Audit Commission.
Carter T, Beresford P (1999). Models of Involvement for Older People. York: Joseph Rowntree Foundation.
Department of Health (2003a). A Catalyst for Change: Driving change in the strategic commissioning of non-acute services for older people. London: DoH. Also available at: www.doh.gov.uk.
Department of Health (2003b). Discharge From Hospital: Pathway, process and practice. London: DoH. Also available at: www.doh.gov.uk.
Edwards M, Miller C (2003). Integrating health and social care and making it work. London: OPM.
Forte P, Bowen T, Foote C, Poxton R (2002). Intermediate Care: Getting the balance right. London: Balance of Care Group.
Garavan R, Winder R, McGee H (2001). Health and Social Services for Older People. Consulting older people on health and social services: A survey of service use, experience and needs. Dublin: National Council on Ageing and Older People.
Hardy B, Hudson B, Waddington E (2000). What Makes a Good Partnership? A partnership assessment tool. Leeds: Nuffield Institute for Health.
Hayden C, Boaz A (2000). Making a Difference: Better government for older people. Evaluation report. Warwick: University of Warwick.
Kaplan RS, Norton DP (1996). The Balanced Scorecard: Translating strategy into action. Boston: Harvard Business School.
Nies H (1992). ‘Research and local planning of services for elderly people: an interactive approach’. Policy and Politics, vol 20:1, pp 1–13.
Nies H (2003). Networks as regional structures for collaboration in integrated care. Proceedings, International Conference on New Research and Developments in Integrated Care, 21–22 February 2003. Barcelona: Institute for Health Studies, Barcelona, Spain.
Poxton R (2003). Health and Social Care Partnership: Working with particular reference to joint commissioning. Briefing paper. London: Institute for Applied Health and Social Policy, King’s College London.
Stevenson J (2001). Mapping Local Rehabilitation and Intermediate Care Services. London: King’s Fund.
Stevenson J, Spencer L (2002). Developing Intermediate Care: A guide for health and social services professionals. London: King’s Fund.
Thornton P, Tozer R (1994). Involving Older People in Planning and Evaluating Community Care – An overview of initiatives. York: Social Policy Research Unit, University of York.
Vaarama M, Luomahaara J, Peiponen A, Voutilainen P (2001). The Whole Municipality Working Together For Older People: Perspectives on the development of elderly people’s independent living, care and services. Helsinki: STAKES.