What Is Integrated Care?
Integrated care is all about teamwork and collaboration and is known as integrated health, comprehensive or coordinated care. It brings together the NHS, local councils, local providers, the voluntary sector, the social enterprise sector and other local organisations to create better services based on local needs. The goal? To improve outcomes for people by joining care and creating better services tailored to local requirements. Through integrated care, we embark on a transformative journey to reimagine how we care for one another, ensuring that every person is seen, heard, and valued.
At the heart of integrated care is a focus on the person. It’s about providing seamless, person-centred support that values each person’s needs. This means different professionals involved in a person’s care must work together to achieve better outcomes. Integrated care should achieve more personal involvement, better planning and free access to helpful information.
To truly embrace the essence of integrated care, we must shift our language and mindset. Referring to people as “service users” fails to capture the person-centred approach that integrated care promotes. Instead, we must recognise that each person is a unique human being with their own story, needs, and aspirations. When we see people as active participants in their health journey rather than passive recipients of services, we encourage them to take charge of their own health and make meaningful decisions.
⇒ Learn more about what case commissioners look for in social care providers.
Why Integrated Care is Becoming a Focus in Health and Social Care
This collaborative approach is extremely important because it has the potential to significantly improve outcomes for people by offering seamless, person-centred support. The current service provision also presents its own set of challenges. With an increasing focus on improving people’s care experiences, quality, and efficiency, the need to reduce health inequalities becomes paramount. Integrated care presents an opportunity to address these challenges by reducing fragmentation within and across services, ultimately supporting more home-based care outside the hospital.
Additionally, wider conditions play a crucial role in integrated care. Factors like education, housing, employment, and community support are all part of the equation. By adopting an integrated care approach, there’s a greater potential to address these broader determinants of health and well-being.
Furthermore, the statutory partnership of integrated care organisations within an integrated care system (ICS) creates a collaborative structure essential for driving change and innovation in the health and social care sector. This partnership, which includes the NHS, local authorities, voluntary and charity groups, and independent care providers, is geared towards creating integrated services that meet the specific needs of local communities. When people receive care from different health and care organisations and professionals working across different providers, the result can be fragmented, challenging to access and not tailored to their specific needs.
Integrated care has the capacity to:
- Reduce delays in care delivery
- Prevent unnecessary repetition
- Minimise confusion
- Eliminate duplication and gaps in service provision
- Prevent people and their support workers from feeling lost in the health system
Integrated Care Systems (ICSs)
Integrated Care Systems are regional partnerships that bring together various health and care organisations to plan and deliver more integrated health services. According to The King’s Fund, these systems were legally established on July 1, 2022, and cover all of England, divided into 42 ICSs, each serving populations ranging from 500,000 to 3 million people.
This includes the NHS, local authorities, voluntary and charity groups, and independent care providers. Each ICS has an integrated care board and works with local authorities to create an integrated care partnership (ICP) committee for each system. And each ICS has an integrated care board (ICB), a statutory organisation responsible for planning health and care services in local areas, managing the NHS budget, and arranging the provision of health services in their area.
While, ICPs are joint committees within ICSs that include NHS organisations and upper-tier local authorities. They are tasked with developing long-term strategies to improve mental health services and social care services and the overall well-being of the population.Integrated care boards are NHS organisations in charge of coordinating health services in their respective communities. Each ICS area has a single ICB. These boards manage the NHS budget and collaborate with local healthcare providers, including hospitals and GP practices, to develop a five-year plan detailing the NHS’s position in the ICP’s comprehensive care strategy.
The integrated care systems aim to achieve several key goals:
- Improving health and social outcomes
- Reducing health inequalities
- Improving productivity and value for money
- Supporting social and economic development
Key Components of Integrated Care Systems
Integrated care systems represent a significant shift in healthcare delivery, enabling a holistic and collaborative approach. At the heart of these systems lie three key components: multidisciplinary teams, coordinated care plans, and a person-centred approach. These vital elements redefine the traditional model of care and focus on seamless collaboration among diverse healthcare professionals, ensuring coordinated and personalised care and placing people at the centre of their care journey.
Multidisciplinary Teams
Multidisciplinary teams (MDTs) serve as structured teams where professionals from health and social care sectors collaborate to meet the needs of people and communities. These teams are the backbone of integrated care, necessitating well-defined roles, robust leadership, and a variety of professional expertise for providing the proper care.
MDTs actively involve the care recipients and their families, making their perspectives central to decision-making. They also liaise with other services and teams within their local areas to offer comprehensive support. The success of MDTs is built on supportive leadership, equal respect among members, and shared access to information, which enhances communication and trust.
Coordinated Care Plans
Coordinated care plans ensure all care professionals involved in a person’s support are well-informed about their needs and preferences. These plans are instrumental in organising care activities and smooth information exchange among all participants, thereby enabling the delivery of high-quality, person-centred care. The main objective of coordinated care plans is to meet people’s specific needs and preferences, ultimately enhancing the quality and effectiveness of care while promoting a person-centred approach. They actively involve the care recipient in their creation, ensuring that essential information is easily accessible and accurate.
Vital components of care coordination involve:
Establishing responsibility
Sharing knowledge through communication
Assisting with care transitions
Evaluating a person’s needs and objectives
Formulating proactive care plans
Integrated care models focus on enhancing coordination and continuity across health and social care providers and settings, with providers collaborating across specialities to ensure unified care plans.
Integrated care results in reduced emergency department visits, lower hospital readmissions, and overall better outcomes.
⇒ Learn more about Why a Delayed Hospital Discharge is a Harm Event.
Person-Centred Approach
Integrated care is challenging to achieve without embedding it in a culture of person-centred care. This approach prioritises the person’s perspective, ensuring that care delivery aligns with their personal goals and values. Person-centred care models the person’s needs and desired health outcomes at the forefront of all care decisions. It encourages active collaboration and shared decision-making among care recipients, families, caregivers, and health and social care providers.
The success of person-centred care in integrated care settings is often measured by people’s outcomes, which reflect their perspective on their health and well-being. Therefore, building relationships based on trust and a commitment to long-term well-being is crucial for achieving positive outcomes.
Government Initiatives and Policies
The UK government has implemented various initiatives and policies to promote integrated care across the country. The Health and Care Act 2022 established integrated care systems to integrate health and social care in England. These systems aim to provide more joined-up services tailored to local needs, with day-to-day operations managed at the place level, generally within local authority boundaries. The Act also created integrated care boards as statutory bodies to take on responsibilities previously held by NHS clinical commissioning groups (CCGs), expecting these responsibilities to be delegated back to place-based partnerships.
Integrated Care Strategies
The local government has issued guidance on preparing integrated care strategies, emphasising the need for local decision-making and considering wider determinants of health. Integrated care partnerships (ICPs) are encouraged to involve a broad range of stakeholders in developing these strategies, ensuring transparency and inclusivity. The strategy should set the system’s direction across the ICB and ICP area, presenting opportunities to innovate beyond traditional health and social care services.
NHS Long Term Plan
The NHS Long Term Plan, published in January 2019, outlines a comprehensive strategy to enhance healthcare services in the UK over the next decade. This plan aims to focus on various health challenges and improve the quality of care through integrated and coordinated efforts. To achieve substantial improvements for care recipients in the next ten years, the NHS Long Term Plan details strategies to overcome challenges like staff shortages and rising service demand by:
Giving people more control over the care they receive and their own well-being
Encouraging collaboration between GPs, their teams and community services
Enhancing the emphasis on NHS organisations collaborating with local partners as ICS plans and providing local services tailored to the needs of their communities
Preventing major health challenges and investing in early treatments to minimise hospital admissions and improve people’s outcomes
Supporting the ageing population by increasing funding for primary and community care
Enhancing the NHS workforce by committing to training and recruiting more healthcare professionals
Leveraging digital technology to improve service delivery and care
The NHS Long Term Plan is a forward-looking strategy designed to transform healthcare in the UK through integrated care.
Case Studies: How the Right Care Creates Better Outcomes
What does it mean to live a fulfilling life regarding health and well-being? How can integrated care and person-centred support transform the lives of people who require complex care? These are the crucial questions that guide our approach to integrated care. By combining efforts across various social and support services, integrated care aims to provide seamless, holistic support that meets each person’s unique needs. It ensures that every person receives the right care at the right time and in the right place, ultimately leading to better outcomes in individual well-being and enhanced quality of life.
At Leaf Complex Care, our in-house multidisciplinary therapy team recognises the uniqueness of each person we serve, and tailors support to meet their specific needs. To gain a wider perspective, please read our case studies.
“We work to make sure that we involve families, social workers and everyone involved in that person’s life so that we get everyone’s views. So, to speak, we make sure everything we do, all interventions are based on PBS and empirical research, serving as best practice for analysing the behaviour of those with whom we work.“ – Amy Butler, Therapy Team Lead / PBS Specialist Practitioner and Coach.
Jacob's Care Journey
Jacob is a young person with lived experience of a brain condition associated with a learning disability. Despite his unique abilities, he expresses himself through behaviours of concern. For Jacob to live life on his best terms, he needs the right care and support enabled by a care team that understands his needs and cares to provide a safe environment for him and his family.
” To get Leaf involved with Jacob, we really had to fight the system to get the package we really needed. Jacob was under the social services residential care, which we didn’t think would meet his needs, and we actively pursued Leaf to support Jacob.” – says Cathy, Jacob’s mum.
James' Care Journey
In 2020, James transitioned from a care setting that brought many challenging moments to a life filled with meaningful activities and the right support. James is autistic and lives with Sotos syndrome and epilepsy, and his journey with Leaf Complex Care created many heart-warming moments of continuous improvement in his overall well-being.
“With good family involvement and working together, we have designed a timetable that means J is really happy. It is not perfect, but it is so much better than in the past. He is happy, he makes choices about what he eats (within reason), where he goes, and what he likes to do. He even chooses what staff he likes. J has the best life with as much control as he can, given his learning disability.“, adds his mother.
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