Why is integrating care so hard? Paul Corrigan talks specialists, supply chains, service users and the Shard

It's quite right that many discussions aimed at improving patient care and service user experience concentrate on how to better integrate care. The experience of fragmented care that patients and users of services have is well documented, and we can see that this disjointed experience is getting worse with the appointment of every new specialist post.

Some of these discussions feel a bit ethereal, but a few start off by recognising the size and ubiquitous nature of disjointed care. They start with the question: “If integration is so very important, how come hundreds of thousands of very good staff are so committed to fragmentation?” Why is fragmented care so persistent and powerful and coordinated care so very hard?

I discussed this issue at a meeting of senior local authority and NHS staff in Leeds, which is part of a Local Government Association (LGA) sponsored project to develop care that is integrated across all the different services. The Integrating Care team that I am a part of is working for the LGA to develop value cases for integration across different services.

Within local government, there has been some progress. The last 30 years has seen some important progress towards integration, with the development of much stronger corporate local authority centres. The move towards one-stop shops has dented many fiefdoms.

When compared to the increasing fragmentation of the NHS over the same period, this is progress. But local government colleagues were the first to point out that this did not mean that citizens had many experiences where their services were fully coordinated.

It is both a good and a bad thing that professionals in the NHS and local government are really passionate about the aspects of care they are responsible for. Of course it's not that people leave work to go home and are pleased that they have disjointed the service user's care pathway; they are pleased that they have had a very good day improving what is usually one very small aspect of a long care pathway.

Professionals are passionate about their small part in the overall pathway, and we have always encouraged them to be so. The entire health and local government system has encouraged professionals to become experts in how X can improve the human condition. They will have received specialist training, been on many courses and will have written and received recognition for the specialist aspects of their work.

And as they get better and better at smaller and smaller things that X represents, I have less interest in all of the other letters of the alphabet that I know make up the totality of care. It is X that defines me. And I am good at X.

Let's be clear here. The division of labour in the NHS and local government has been, is and always will be a good thing. I guarantee that you would not want me to either build your social housing or carry out a hip replacement. I do not have those skills and we need the people who do that work to have very finely honed and specialist skills.

Coordinated health and social care must not be built around any belief that everyone can do everything. They can’t. As with every other industry and service, the division of labour is a very good thing. BUT, in every other industry, encouraging staff to have a passion for small bits of activity means  there is someone who has responsibility for the whole.

I write this post looking at the Shard in London Bridge. Thousands of very specialist, skilled workers were used in building and fitting out the Shard. It works only because of those skills.

But the difference between the Shard and the problem of fragmented social and healthcare is that in building it, someone was totally responsible for the whole project. The best glaziers in Europe only turned up to do their work after the best builders had built the floors and the structure. The Shard worked because someone more important than all the specialists made the whole supply chain of specialists work. Someone stood up for the whole building and ensured that the specialists worked together.

In developing integrated care, we must continue to recognise how important crucial specialist skills are. But we need someone to stick up for the service user, who has more power than all the specialists, to organise them into a single and simple supply chain that forms their skills around the user.

Paul Corrigan is a management consultant and executive coach. For more information on the Integrating Care team he is part of, please visit www.integratingcare.org.

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