The feasibilities and practicalities of the integrated working journey: exploring the development and implementation of a whole population approach to delivering person-centred care within the United Kingdom

摘要

Introduction : The demographic shift of an ageing population increases demand on health and social care services, in a time of limited resources. Services are currently faced with the challenge of providing high quality, patient-centred care to a population who are increasingly living with multiple complex long-term conditions. This often results in care from multiple providers, subsequently increasing the risk of duplication, inefficiency, poor coordination and experience. Services therefore urgently need to work in partnership in order to deliver person-centred care. Methods : A qualitative study utilising in-depth semi-structured interviews with representatives from strategic roles was undertaken to explore perspectives of developing and implementing integrated services across organisations. The strategy includes a shift from working in organisational silos to delivering integrated care to the whole population. Primary data were collected in a rural setting within the United Kingdom. Data were transcribed and analysed using a thematic analysis approach. Results : Data were grouped into six themes including: focus and purpose of the integrated concept, multidisciplinary team working and engagement, professional roles and responsibilities, contextual factors and challenges of integration, expectations and the reality of integration, and aspirations and future goals for care delivery. Transferable key enablers for progression included a clear shared vision, organisational commitment, cultural change, individual behaviours and personalities, and period of stability in workforce and leadership. The systemic, organisational, and professional challenges experienced are likely to be represented across initiatives aiming to integrate care. Discussions : Despite extensive research and policy changes, initiatives continue to experience similar barriers in progression with integration and population health management. Robust case study designs and in-depth qualitative explorations into the experiences of those developing approaches to improve care delivery, add essential value to understanding associated barriers and facilitators. These findings are therefore highly relevant to those developing integrated care initiatives across international contexts. Conclusions : While a combination of relational and technical aspects are necessary for progression, the success of the initiative was largely perceived to be dependent upon the workforce, and individual behaviours and personalities rather than processes and structures. In light of the often underestimated lengthy process of large-scale system transformation and organisational change, it was apparent that the initiative remained in its infancy. As health services run on people and not processes, relational aspects and increased workforce investment may therefore hold the potential for success and sustainability of integrated approaches to care delivery. Lessons learned : The need to start small and scale up, invest time in building relationships and peer support, and focus on proactively supporting people, before expanding models, were highlighted. Limitations : Whilst the appreciation of the contribution of contextual factors to the challenges of integration are transferable, the case study nature may limit the applicability of some aspects. A further potential limitation includes the inferred organisationally representative nature of the participants in their perspectives of strategy development. Suggestions for future research : There is the need to develop approaches to measuring outcomes which account for impacts at the individual patient and professional level. Explorations into integrated workforce development is also advocated.