Challenging conceptions of integration: sharing the findings from a Practitioner Research Programme on improving the care of older people in Scotland

Catherine-Rose Stocks-Rankin (IRISS, Glasgow, UK)
Claire Lightowler (University of Strathclyde, Glasgow, UK)
Heather Wilkinson (Centre for Research on Families and Relationships AND School of Health in Social Science, University of Edinburgh, Edinburgh, UK)

Journal of Integrated Care

ISSN: 1476-9018

Article publication date: 16 June 2014

1070

Citation

Stocks-Rankin, C.-R., Lightowler, C. and Wilkinson, H. (2014), "Challenging conceptions of integration: sharing the findings from a Practitioner Research Programme on improving the care of older people in Scotland", Journal of Integrated Care, Vol. 22 No. 3. https://doi.org/10.1108/JICA-04-2014-0015

Publisher

:

Emerald Group Publishing Limited


Challenging conceptions of integration: sharing the findings from a Practitioner Research Programme on improving the care of older people in Scotland

Article Type: Guest editorial From: Journal of Integrated Care, Volume 22, Issue 3.

Introduction

Currently the concept and practice of integration is high on the Scottish policy and practice agendas as the Public Bodies (Joint Working) (Scotland) Bill (Scottish Parliament, 2013a) moves through the legislative process. The Bill aims to deliver a structure for Scotland's system of health and social care to deliver more joined-up, person-centred care, and to produce better outcomes for patients, service users and carers. Despite the contested nature of integration, the Policy Memorandum accompanying the Bill states: “reform based on centrally-directed structural changes would be unlikely to deliver the shift in outcomes required” (Scottish Parliament, 2013b, p. 157), thereby recognising the importance of front-line practice in delivering and sustaining effective changes in the implementation of integration.

It is against this shifting context that the papers in this special edition explore and illustrate a more nuanced interpretation of integration, drawing on front line practice across a range of services providing health and social care for older people. These examples and interpretations have emerged from the findings from an Economic and Social Research Council (ESRC) funded project called Practitioner-Research: Older People (PROP).

The project in itself was a collaboration between the Centre for Research on Families and Relationships (CRFR), University of Edinburgh and Institute for Research Innovation in Social Services (IRISS). Project partners were drawn from a group of Scottish Local Authorities, NHS, third and independent sector organisations and included NHS Lothian, West Lothian Council, Glasgow City Council, Alzheimer Scotland, and Scottish Care and VOCAL Midlothian and Midlothian Council.

The aim of the project was to support a range of individuals to undertake a set of practitioner research projects all focusing on an aspect of health and social care for older people.

Contributions from some of the practitioner researchers form the content of this special edition. Their findings challenge and stretch current conceptions of integration found in policy and research discourse, and in doing so, we believe both further our understandings of integration as enter the next phase of integration in Scotland, but also highlights the importance of hearing the practitioner's voice alongside those of policy makers, researchers and older people themselves. In fact this collection for us demonstrates that if change of the scale of health and social care integration is to achieve its potential it requires an integration of knowledge and expertise from across practice, policy, research, older people their families and communities, in addition to the integration of services, systems, processes and cultures across health and social care.

Context of the PROP project

The context of the PROP project, as the papers in this issue reflect, was a mechanism of integration. Through the practitioner-research programme, we were able to test a model of integrated working which continues to offer incisive lessons on the processes of integration and the enablers which facilitate its success. For us, a key attribute of integrated working involves shared outcomes and a shared framework of activity. But within this shared context, the practice of integration included a division of roles and responsibilities. Individual ownership over these roles was a key strength of our project, as was the space for shared reflection and learning. Together, these two strands of the PROP project reflect our wider learning about integration: a shared vision and value-base combined with a shared process provides the framework for integrated working and within this shared context, individual ownership of programmes and practice can flourish.

The PROP project was carried out over 17 months between May 2013 and September 2013. In that time, we delivered a research training programme for a small group of practitioners working in the Scottish health and social care sectors. The practitioners involved in PROP produced empirical research evidence to support improvement in health and social care for older people. As part of their research process, they presented their research at specific PROP-funded knowledge exchange events and produced a range of outputs including research reports, postcards about their research and a booklet summarising the key findings.

For the practitioners, the PROP project included dedicated research and knowledge exchange training days, and time for knowledge exchange as well as the support from their organisations to secure 1/2 day per week for research leave. Within the research and knowledge exchange training days, we ran workshops on key elements of the research design process such as research ethics, qualitative and quantitative methods, data analysis, and so on. We provided training about different communication methods and approaches to sharing research findings. Within these sessions there was also dedicated time for practitioners to share their learning and reflect on the challenges of doing and sharing research within their practice context.

Shared learning was enabled through the dedicated time away from practice. Training sessions were held at the university, which allowed practitioners to focus on their learning rather than the demands of practice that they tend to prioritise. Shared learning was also facilitated by the lack of hierarchy within the training process. Practitioners of different professional grades and expertise occupied the same position within the project. Everyone's learning was valued and individual capacity was respected and supported.

Shared learning was further supported through designing activities and creating roles to facilitate an exchange of knowledge between people from different professional backgrounds, and thus familiar with specific forms of knowledge. Workshop hosts came from a range of policy, practice and research backgrounds, thus implicitly highlighting the value being placed on different forms of knowledge and expertise. A member of the project team who was present throughout the training journey translated formalised academic knowledge, where necessary. Similarly, practitioner knowledge was translated by the practitioner researchers for the benefit of each other (particularly given the range of contexts they came from) and the project team. Each practitioner was paired with a mentor that supported mutual learning about the practice world (for mentors) and the research world and process (for the practitioners). The mentors also helped in the design and timely delivery of the research outputs.

An insightful example of this process is reflected in our approach to writing this special issue. We used a residential writing retreat to carve out dedicated time for the practitioners, project team and mentor to write this special issue. The authors of the articles within this special issue spent two days together to think through the concept of integration in relation to the empirical research produced as part of the PROP project (integration was not necessarily the initial focus of these individual research projects). Taking time away from our day-to-day contexts (both professional and personal) created a valuable space for reflection. The time away was also time spent together, and that meant that we had scope to reflect, collaborate and share, when and where we found this to be valuable.

Like other elements of the PROP project, our roles were distinct. Each practitioner had an article in which they were the lead author and the project team had a designated role to support the analysis and writing process. Likewise, as editors we had a role to play in the synthesis of key themes across the articles. In this way, the authorship of this opening paper is ours, while that of the remaining papers belongs solely to the practitioners and mentor involved. There is a division of roles and clarity of responsibilities, but there is also a joint aim and a shared set of outcomes for all those involved. The knowledge presented here is a result of collaborative working and shared learning.

We have also produced, what we feel to be, a new and insightful set of empirical reflections on integration in short period of time. As some of the papers go on to express, integrated working can be time-consuming and delicate, but when it works, the outcomes far outweigh the work that would have been produced without it.

Re-defining integration

In policy and academic discourse integration is commonly equated with organisational integration. Within Scotland the policy shift to a focus on integration goes back to Designed to Care in 1997, followed by Partnership for Care in 2003. These policies were implemented in practice through the formation of the Joint Improvement Team and Community Health Partnerships (cf. Harries and Cook this edition for more policy detail and analysis). Debates around integration are currently taking place in the context of legislation before the Scottish Parliament focused on a specific form of organisational level integration between Health and Social Care services (Public Bodies (Joint Working) (Scotland) Bill; Scottish Parliament, 2013a). The Public Bodies (Joint Working) (Scotland) Bill, 2013 is focused on the integration of local authority services with health services. Despite this specific focus, the aspiration of the Bill is to achieve seamless services from the perspective of the service-user or carer. This invites a broader vision that the integration of local authority and health services.

Recent reviews of the evidence base for the effective delivery of integrated adult health and care services (Petch, 2011, 2013 both undertaken for ADSW), argue that there are a number of factors above and beyond structural change that result in improved outcomes for service users and communities (Petch, 2011). The most recent review (Petch, 2013, p. 28) clearly articulates that: the factors likely to have greater impact on the delivery of acceptable outcomes for individuals are those which focus on leadership, on vision, and on context”.

The papers in this collection argue for a broader view of integration than commonly presented in policy and research. The arguments here build on Petch's categorisation of three levels of integration: the micro (individual), meso (service delivery) and macro (strategic) (Petch, 2011). We make the case that integration needs to be examined across all three of these levels. As part of this argument, the papers in this special issue offer new definitions of integration rooted in the practice context.

Caine asks us to think of integration as a process that occurs beyond the formalised structures of health and social care. Through her research on music and people with dementia, Caine is interested in facilitating individual engagement in service design as a form of integrated delivery. Caine considers integration as a process in which people who access support and their carers are included in the design and delivery of services. In her contribution to this special issue, she reflects on her use of a Participatory Action Research methodology to include service users and carers in the research design of her project on music and wellbeing.

The two papers from Tsegai and Gamiz offer new conceptions of integration. In their first paper, they propose that carers are key co-ordinators of care in their management of a variety of formal and informal support. Therefore, they argue that carers already play an important but often unrecognised role in the integration of services that would benefit from further consideration (Tsegai and Gamiz, 2014). In their second paper, the authors suggest that collaboration between statutory and voluntary services can be a means for achieving improved outcomes for people (Gamiz and Tsegai, 2014). They make the case that research is a tool of collaboration and outline the possibilities, as well as the challenges, of integrated working.

These definitions ask us to re-conceptualise integration a process which includes people as well as organisations or systems. For these practitioners, integration is a process and it functions best when the people who access support, their carers, networks of support and wider community are included in that journey. Likewise, integrated working between practitioners is emphasised and explored as way to understand wider shifts in organisations and systems. Integration, as explored in this special issue, is a people-focused process first and foremost.

The paper by Harries et al. uses the illustration of the “zip” to describe how far health and social care services connect in practice, to contextualise some of the wider messages from the practitioner's papers against the current context of integration in Scotland and the importance of these findings in addressing the policy pressure across the UK to “zip down” the divisions between health and social care.

Broadening the scope of our definition of integration has important implications for practice and the experiences of people who access support. As Tsegai and Gamiz suggest, poor integration of people into the process has real world impacts. Carers who participated in their study were found to be “a fountain of knowledge” and yet that expertise was found to be missing within or between services. Carers voiced their frustration with having to “go through it again and again”, emphasising the effort required for people to repeatedly engage with different service providers.

Mechanisms which support integration

The empirical research underpinning our examination of integration offers insights into the mechanisms and enablers which support integration. We outline and explore two mechanisms emerging from this collection, and deeper reflections on these emerge across each of the core papers of this special issue.

Outcomes focused conversations

As Tsegai and Gamiz point out, an outcomes focused conversation rather than paper assessment tools were instrumental to the creation of meaningful engagement with people who access support. The authors echo our argument above that successful processes of integrated working often involve clear roles and responsibilities. For Tsegai and Gamiz, the carers who participated in their research were clear about their expectations for communication. They suggest that “taking time to engage meaningfully can therefore mean that carers feel their expertise is being recognised, and is also likely to provide professionals with better insight into carers’ perspective” (Tsegai and Gamiz, 2014).

This perspective is echoed by learning from the PROP project more broadly. For example, Colston (2013) shows the value of “peer support” and “community connections”, two of the five pillars of support outlined by Alzheimer Scotland. Colston (2013) goes on to underline the value of re-thinking integration from the perspective of the person who accesses support and their carer, and the importance of engaging with peers and the wider community to achieve the outcomes that are important to them. Through this work she highlights the ways in which the outcomes for people who access support can be included at a macro, meso and micro level of integration.

The insight from these papers extends to the social services beyond the issue of integration, highlighting the importance of the mode, tone and focus of engagement. What emerges from this collection is that each contact between those delivering and those receiving support services can and should be seen as a mechanism of integration: every contact is an opportunity to work in partnership.

Practitioner research

Across this collection there is evidence of the process of undertaking practitioner research and the findings generated through practitioner research helping to improve integration and the broader experience of those accessing support services. Therefore, we argue that the papers in this collection demonstrate that, and illustrate how, practitioner research as an activity in itself can be a mechanism to support integration.

In part, positive joint activities of any type, bringing together people with similar goals from different backgrounds and working across different services is likely to support integration through strengthening connections, understanding and improving communications. But we argue that practitioner research represents more than this. Because practitioner research is an inquiry around a real, directly experienced practice issue what emerge from the process are, in part, concrete ideas about change and improvement.

Further, the people who then know most about what has emerged from the process, and who have a personal investment in it, can often also play a role directly in supporting some of the changes identified. Practitioner research projects such as those highlighted here can achieve integration not only at a micro (individual) level but also at a meso (service delivery) and macro (strategic) level. The following examples highlight specific improvements relating to integration across the three levels for some of the practitioners involved in the PROP project (for more detail see Stocks-Rankin et al., 2013a, b).

For Caine, production of the research produced concrete impacts. At an individual level, there were clear benefits to her practice. In particular, the use of participatory and creative methods strengthened her belief in the value, and ethical dimensions, of including people who access support in the design and delivery of services, integrating those being supported and those providing support. At a service delivery level, the use of music for people with a diagnosis of dementia and their carers added new dimensions to the service provided. It supported the integration of the carer into the support provided and developed new creative ways of integrating people who access support.

Similarly, Colston's (2013) research on Alzheimer Scotland's early stage support for people with a diagnosis of dementia has had impacts on her own practice and the delivery of services. As she describes in her report on the project, this research changed the way support was provided to a group of people involved in the research. The proximity of the researcher in a practitioner-research project like PROP can enable the integration of research into practice.

As the PROP project came to a close, Alzheimer Scotland was promoting this evidence and highlighting the benefits of music-therapy, early-stage support and practitioner-led research. This organisational-wide interest reflects the possibilities for macro-level changes.

This organisational-wide change is echoed by the Tsegai and Gamiz's research on carer's assessments. Given their role as co-researchers from different organisations, Tsegai and Gamiz found that the PROP project supported critical thinking and reflection, particularly in terms of the taken for granted processes, tools and language used in their respective organisations (see Tsegai and Gamiz, 2014). At a strategic level, this research has supported the development of a new pathway, a redesigned carer's assessment and a new carer's assessment review tool. These changes are anticipated to lead to changes in the mode of support offered; in particular a focus on conversation-based processes is now being used in Midlothian Council's social work support for carers.

Thus, their findings are informing direct improvements to practice, and the emerging shared understanding across their respective organisations, and crucially also a recognition of the different roles each organisation plays, is helping the organisations to better work together as well as improving the integration of the person supported, the carer and professional support services and providers.

These mechanisms highlight the value of re-defining integration as a process that is focused on shared pursuit, or co-production, of outcomes. Conversation-based tools encourage each party to use and share their expertise. Similarly, practitioner-led research draws on the expertise of practice and combines that with the insight gained from robust inquiry. In each case, integration relies on the skills, experience and effort of the people within a system.

Enablers of integration

In addition to specific mechanisms which support integration, the collection identifies enablers of integration, which run through the findings, sometimes implicitly and unnoticed, but in reflecting on these contributions we contend that their absence would make integration significantly more challenging.

Common purpose

Tsegai and Gamiz found that joint working was facilitated by an agreement that outcomes were at the heart of their approach to practice, and thus, at the centre of their research project.

This echoes findings and discussions elsewhere that activities involving diverse perspectives, such as those between researchers, practitioners, policy makers, service users and carers function well when “there was general agreement from all stakeholder groups that the primary purpose of partnership working should be to deliver better outcomes to service users and their carers” (Cook et al., 2007, p. 4).

Shared ownership

Shared ownership was also found to enable integrated working. At a micro level, practitioners who research are able to change their own practice. They sidestep the need for shared ownership between the research and practice fields by developing a hybrid approach to both. For example, Colston's (2013) research during the PROP project reported on service-level changes that she made in response to her own research findings. Practice-led inquiry has the capacity to immediately integrate research evidence into the design and delivery of services.

In her paper, Caine (2014) offers concrete insights into the enablers and challenges of integrated working. She concludes that successful integration is supported through dedicated time and active listening so that shared ownership and meaning can be created. Importantly, Caine highlights that shared power and control are resources for creating trusting relationships. Her reflections as a practitioner, whose research overlapped her practice, offers us the tools for testing new ways of working and the emotional and ethical insights necessary for creating a fertile space for integration.

Creativity

This special issue give further insight into the creative ways that practitioners facilitate change in their organisations. Caine used creative methods in her research to ensure that participants could share their experiences in their own words. Gamiz and Tsegai used Google drive to share documents and carry-out joint writing. This tool allowed them to circumnavigate some of the institutional barriers to sharing information across organisations. Practitioners who are solution-focused can work around organisational barriers in creative way. On the PROP project, this creatively enabled partnership working (Gamiz and Tsegai) and ensured the inclusion of wider range of research participants (Caine).

Self-reflection and joint discussion

As these papers indicate, self-reflection was a key element of the research process. It allowed practitioners to see their work and the work of their organisation differently. On the PROP project, this process of reflection was strengthened by the group discussions we facilitated at training events and on-line in the virtual learning environment created for the project.

Together these two processes of reflection enabled practitioners to integrate their learning and build the necessary links between the development of their research and the changes in practice they wished to see. Group discussions validated and further developed these thought processes. As we detail in our evaluation reports on this project, this discursive process was thought to have a “re-boot” effect. As one practitioner noted: “‘a change is as good as a rest’ – it's reminded me to not just work on a production line but to speak up and try to work to my own standards, values and ethics as opposed to the demands of the machine” (see Stocks-Rankin et al., 2013a, p. 26 for more detail).

This is further echoed by Gamiz and Tsegai (2014) paper that argues “research provided an opportunity to look beyond the frontline of our everyday practice, and provided opportunities to learn about and influence matters at both a service and strategic level”.

Mentorship

Mentorship was found to be an invaluable support for integrated working, particularly in terms of the practitioners’ development of a boundary-spanning role that straddles both practice and research. As MacArthur (2014) illustrates, mentors supported practitioners to bridge their learning about research into their existing practice expertise. This facilitated through several mechanisms: research advice, quality assurance and emotional support throughout the research process. MacArthur's insights echo her own role as a knowledge broker between research and practice. Her guidance of practitioners in the NHS required knowledge of their practice contexts as well as the requirements of rigorous research. As MacArthur describes, she supported practitioners to gain confidence in their new boundary-spanning role and the value of the research itself. Even where research was unable to be completed, MacArthur's role supported the practitioner to find value in the work that had been completed and support them to new avenues to encourage completion of the project. MacArthur is a boundary-spanner herself and was well placed to understand the demands of practice and research.

Conclusion – a more nuanced view of integration

This paper has highlighted the value of disaggregating integration to focus on the people who work to create integrated practices. This is emphasised by Tsegai and Gamiz's claim (this issue) that a differentiation of services and support can be beneficial to service users. They suggest that in some areas, differentiation between services might contribute to better outcomes for people and underscore the idea that a focus on integration which gives primacy to the blending of organisations or systems can be detrimental to the needs of service users. Instead, they and the other authors in this issue, offer a sense of the person – the practitioner, the carer, the people who accesses support – at the heart of the integration debate.

We came to these conclusions through a model of co-inquiry. The writing of this special issue has modelled integrated working. It is co-owned by those involved and a product of process in which roles were distinct by the process of inquiry was shared. Practitioner Research has offered each of us a space to reflect on practice issues and re-think our own work as well as the conceptualisation of that work with the policy and practice field. In redefining integration as people coming together to pursue shared outcomes the mechanisms for supporting it emerge include outcome-based conversation and practitioner research itself. Overall the collection highlights the importance of integrating the practitioner perspective and knowledge with research, policy and the service user knowledge and experience.

Catherine-Rose Stocks-Rankin

IRISS, Glasgow, UK

Dr Claire Lightowler

University of Strathclyde, Glasgow, UK

Professor Heather Wilkinson

University of Edinburgh, Edinburgh, UK

References

Caine, J. (2014), “Integrating people with dementia and their carers into service design”, Journal of Integrated Care, Vol. 22 No. 3, pp. 91-98

Colston, G. (2013), Perspectives on Early Stage Support for People with a Diagnosis of Dementia and Their Carers, CRFR/IRISS, Edinburgh

Cook, A., Petch, A., Glendinning, C. and Glasby, J. (2007), “Building capacity in health and social care partnerships: key messages from a multi-stakeholder network”, Journal of Integrated Care, Vol. 15 No. 4, pp. 3-10

Gamiz, R. and Tsegai, A. (2014), “Beyond practitioner-research: integration to outcomes”, Journal of Integrated Care, Vol. 22 No. 3, pp. 108-116

Harries, J. and Cook, A. (2014), “Conclusion”, Journal of Integrated Care, Vol. 22 No. 3, pp. 123-127

MacArthur, J. (2014), “The role of mentors in integrating research and practice”, Journal of Integrated Care, Vol. 22 No. 3, pp. 117-122

Petch, A. (2011), “An evidence base for the delivery of adult services”, Report commissioned by ADSW

Petch, A. (2013), “Delivering integrated care and support”, Report commissioned by ADSW

Scottish Parliament (2013a), “Public Bodies (Joint Working) (Scotland) Bill”, available at: www.scottishparliament.uk/S4_Bills/Public%20Bodies%20Bodies%20(Joint%20Working)%20(scotland)%20Bill/b32s4-introd-pm.pdf (accessed 15 January 2014)

Scottish Parliament (2013b), “Public Bodies (Joint Working) (Scotland) Bill: Policy Memorandum”, available at: www.scottishparliament.uk/S4_Bills/Public%20Bodies%20Bodies%20(Joint%20Working)%20(scotland)%20Bill/b32s4-introd-pm.pdf (accessed 15 January 2014)

Stocks-Rankin, C.R., Lightowler, C., Wilkinson, H. and Morton, S. (2013a), Assessing the Impacts of New Research Evidence in Health and Social Care Scotland: PROP Contribution Story 2, CRFR/IRISS, Edinburgh, available at: http://blogs.iriss.org.uk/prop/contribution-analysis (accessed 15 January 2014)

Stocks-Rankin, C.R., Wilkinson, H., Lightowler, C. and Morton, S. (2013b), Becoming a Boundary-Spanner Through Practitioner-Research: PROP Contribution Story 1, CRFR/IRISS, Scotland, available at: http://blogs.iriss.org.uk/prop/contribution-analysis (accessed 15 January 2014)

Tsegai, A. and Gamiz, R. (2014), “Messages for integration from working with carers”, Journal of Integrated Care, Vol. 22 No. 3, pp. 99-107

Further reading

Government of Scotland (2013), Public Bodies (Joint Working) (Scotland) Bill, Policy Memorandum, Government of Scotland, Edinburgh

Petch, A., Cook, A. and Miller, E. (2013), “Partnership working and outcomes: do health and social care partnerships deliver for people using services”, Health and Social Care in the Community, Vol. 21 No. 6, pp. 623-633

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