The process of integrating care in the UK:
Some reflections

Peter Thistlethwaite

Journal of Integrated Care founding editor

I want to thank Axel Kaehne for the opportunity to contribute to the 30th Anniversary Issue of this journal. I helped to found the journal, steered its development, and edited it for 20 years until my retirement. I am delighted to note both its progress and, in particular, its wider international reach.

Integrated care is not difficult to grasp as an idea, but it is mighty difficult to put into practice - either to benefit service users or to increase efficiency in the use of resources. Consequently, the founding imperative of the journal was to secure and disseminate relevant practical evidence of benefits and problems, and thereafter to challenge and support policy makers and implementers in its application.

One word summed up the environment for integrated care at the time: “barriers”. Even the most avid and powerful devotees could be daunted and deflected by these. Many barriers are still there, for example: the way in which most professionals are separately trained for their jobs; varying employment structures and cultures; myths and prejudice about each other; the jealous guarding of individual budget allocations; empire building by managers and politicians alike; the daily grind of doing one’s current job; etc….

I was a policy maker and implementer in social services at the time the journal was born. But I had had a conversion early on in my career when working with two senior people from my locality (an Education Director, and a Public Health Director) both of whom had served on national Commissions, the conclusions of which had emphatically recommended inter-agency working and multi-disciplinary practice. I tried to follow their lead in my work. I must nevertheless acknowledge that national policy was also influenced by these recommendations, and new funds were made available to support joint working. Sadly these were always an add-on to the status quo, rather than a means to integrate prevailing structures and operations. The social care and health care divide has proved particularly intractable.

Later, in another locality, as the Cochrane Collaboration was just beginning to stimulate evidence-based medicine, I was thrown together with a group of general practitioners and community health specialists to look at the application of this discipline in our work. At the first meeting, we had a learned presentation on the failure of medics to drop the use of a specific drug despite the evidence from many studies over many years of its limited benefits. However, in the discussion which followed, one GP highlighted prevailing barriers: “Do you think I’ll have time in a busy surgery to look up the latest evidence on an in-growing toenail before dealing with the patient?” But within a few months that GP was a leading light in the promotion of evidence-based practice. He had had a conversion too, and I had had a second one: to consider the application of the evidence of more “integrated care” in policy and practice.

Soon after, I was pleasantly surprised to be invited to take on this journal, so it is with some delight that, 30 years later, the description of the journal by Emerald (the second publisher) still reflects my then position:

The Journal of Integrated Care (JICA) facilitates the dissemination of research and practice relevant information about the integration of health, social care and other community services to the benefit of service users, patients and health care providers.

And furthermore in its Aims and scope:

JICA is vital reading for managers and practitioners responsible for commissioning, planning and providing care services, as well as academics studying or evaluating policy.

Very soon, the UK parliament will finalise legislation to cement the creation of Integrated Care Systems (ICSs) by local NHS bodies and local authorities. This sounds like a pretty good outcome for those who have tirelessly promoted integrated care over the years. Despite brave innovative approaches in various parts of the country to create a simpler, streamlined experience for patients, and more recently some formal piloting, it has nevertheless taken more than thirty years to arrive. The legislation looks likely to have most traction however on integration within the NHS, which, although a fragmented organisation, is subject in practice to over-centralised controls. A policy of “subsidiarity” allowing specific de-centralisation to localities would provide, in my opinion, more fertile ground for creative integrated care that actually gives people a better experience.

A massive further complication in the UK is the chronic under-funding of social care which the current government has promised to address. With a significant number of hospital beds occupied by patients who are fit for discharge but who cannot be guaranteed an appropriate level of social care in the community, why is a single budget for health and social care services apparently not being pursued to break the mould? It shouldn’t matter which body controls the budget if services are integrated, and it would certainly enable smoother responses to individual needs and choices about care.

From the perspective of the individual patient therefore, it has to be a moot point whether the established barriers to integrated care will in fact be removed or overcome in the foreseeable future. I am sure this journal will rapidly proceed to receive many papers analysing these plans and their likely impact.

It would be good to hear again from old friends still serving the journal.