Fragmentation or integration: A mixed case study of integrated care services for older people with high support needs.

Background: Implementation of the Social Services and Wellbeing (Wales) Act (2014) (SSWWA) in 2016 required Local Authorities to provide integrated health and social care services for older people with high support needs. Care services are currently provided by statutory (health, social services) and non-statutory (third sector, independent sector) organisations. The aim of this research was to assess inter and intra-organisation collaboration in delivering care to older people with high support needs.

Method: Mixed methods case study design. This study was conducted in a Local Authority in North Wales, United Kingdom. Social Network Analysis (SNA) methodology was used to describe the strength and direction of each organisation’s relationship to other organisations in the care network. In-depth semi structured interviews were conducted with service providers/commissioners (n = 14) and service users and carers (n = 5). Measures of SNA were used to provide information about which organisations were linked, the number of links in the network, the types of interactions between organisations and the level and quality of each relationship. Linkage between organisations was measured using degree and density measures. Interviews were transcribed verbatim and anonymised before entering into QSR NVIVO 10. A thematic analysis approach was used to identify patterns across the data with the analysis taking a data driven inductive approach. The range and variation of themes was mapped using data displays.

Results: The results of the SNA revealed weak integration between organisations on all measures. Further analyses at a sector level revealed the highest levels of integration occurring within the health sector and the lowest within the independent sector. Five major themes emerged from the qualitative analysis relating to: partnership working, awareness of other organisations, referrals, thresholds and sharing resources, reflecting the findings of the SNA. Older people with high support needs were mainly unaware and unconcerned about service integration issues when their needs were being met.

Discussion: The findings of this research have implications for policy makers and service commissioners/providers. Despite the requirement of the SSWWA for more integration of care services this was not evidenced. Rather, findings demonstrated fragmentation of services. Organisations know about each other, but few interact. This may be attributable to: a lack of knowledge, recognition and awareness of organisations within the network and the services and skills they can provide; the current commissioning model encourages organisations to compete against each other for contracts and; certain organisations/services would not benefit from integration.
Conclusion: Although the SSWWA is a policy driver, service integration at a whole system level between organisations providing care services for older people with high support appears to be fragmented.

Limitations: This research was conducted as a case study, therefore, results cannot be generalised. Furthermore, the process of bounding the network for the SNA may have resulted in the possibility of leaving out organisations that should have been included.

Future research: Longitudinal research is required to measure changes in service system integration over time.