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Integration, cooperation and partnerships workbook1. How to use this workbookThis work book forms part of the suite of learning materials that have been developed to support the implementation of part one of the Care Act 2014. These materials summarise and explain the ‘Care and Support Statutory Guidance’ (October 2014) [“the guidance”] and are designed to help those involved in care and support services to understand and implement the Act.

The suite of learning materials contains workbooks, PowerPoint presentations and other material for each of the following topic areas:

1. Introduction and overview

2. Information and advice

3. First contact and identifying needs , including assessment and eligibility, and independent advocacy

4. Charging and financial assessment , including deferred payment agreements

5. Person centred care and support planning , including personal budgets, direct payments and review

6. Transition to adulthood

7. Integration, cooperation and partnerships

This workbook is about the integration, cooperation and partnerships requirements of the Act and its statutory guidance. It has been written for learning facilitators and includes exercises, suggested group discussions, and points of reflection that facilitators can use either in their entirety or to pick and choose from as they see fit when designing a learning programme based on the PowerPoint presentation. The workbook can also be used by individuals who wish to learn more about this topic area. You can watch the presentation, read the notes below, and undertake the exercises at a pace and time to suit you.

As well as this workbook and PowerPoint presentation, there is also a summary of what the Act says and a shorter, overview presentation on this topic area.

The implementation of the Act requires whole systems change and underpinning this is a need for cultural change. These learning materials alone will not affect such change, but they are one tool that can be used to support people along the journey.

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In many instances, implementing the Act successfully will require those involved in the care and support system to change the way they work i.e. behaviour change. Research suggests that the way people behave is influenced by their knowledge, skills and attitudes:

The PowerPoint presentation and summary are designed to increase knowledge about the Act or guidance. The questions and exercises in the workbook are designed to spark conversations that encourage people to reflect on their own attitudes and the attitudes of others. They aim to give learners the opportunity to discuss the complexities of implementing the changes in practice, and/or provide a safe way of challenging attitudes that go against good practice.

Key learning pointThese are used in the workbook as a way of highlighting changes that are likely to have a significant impact on practice i.e. the major changes that the Act brings in.

The facilitators’ hints and tips in the workbook signpost facilitators to existing good practice resources on this topic area and/or highlight key changes that are likely to have the most significant impact on practice. The aim is to help facilitators to design interactive learning programmes that are appropriate for their audience.

Knowledge

AttitudesSkills

Behaviour

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Facilitator’s hints and tips

To successfully facilitate this module we suggest that you need to:

have read the relevant sections of the Act, regulations and guidance

have a good understanding of best practice in this topic area, including understanding the Better Care Fund plans agreed in the locality

remember that there are various modules available and you need to choose the most suitable ones for your learning programme

also remember that you can pick and mix questions, exercises and case studies from this workbook or from other topic areas

design your training session in a way that accounts for the learning pyramid so as to maximize the experience and learning outcomes for your participants

Source: Adapted from National Training Laboratories, Bethel, Maine

Lecture 5%

Reading 10%

Audio visual 20%

Demonstration 30%

Discussion 50%

Practice by doing 75%

Teach others 90%

Passive teaching methods

Average retention rates

Participatory teaching methods

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2. Who is it for?

This workbook is about integration, cooperation and partnerships. It explores Sections 3, 6, 7, 22, 23, 43, 74 and Schedule 3 of the Act and the Provision of Health Services Regulations. It is intended to be used to develop learning programmes for:

those responsible for planning and delivering integrated care and support. This would include lead commissioning staff in Adult Social Care, the CCG and in other elements of the local authority such as planning and housing

managers in adult social care and in other parts of the local authority, health services (including the acute trusts, private hospitals, ophthalmic and pharmaceutical services) and housing providers. This would include managers of local authority, private and voluntary sector service providers

those involved in the governance of these organisations, in particular elected members and others who may sit on Health and Wellbeing Boards

staff who are impacted by, or likely to be impacted by, greater integration, cooperation and partnership working and who wish to understand some of the legislative and strategic implications of the Act.

3. Contents

This workbook starts with an overview, which summarises the topic area and identifies key words relevant to this topic area. It then contains the following sections that match the slides in the PowerPoint presentation:

Introduction What the Act says and the duties that fall to local authorities The duty to promote greater integration The duty to cooperate Integration, cooperation and partnerships in practice Working together: examples Summary

Appendices: Links to key resources

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4. OverviewIntegration, cooperation and partnerships have been a cornerstone of public policy, particularly across health and social care, for many years. The Care Act now makes integration, cooperation and partnership a legal requirement on local authorities and their public sector partner agencies. The guidance states that “For people to receive high quality health and care and support, local organisations need to work in a more joined-up way, to eliminate the disjointed care that is a source of frustration to people and staff, and which often results in poor care, with a negative impact on health and wellbeing. The vision is for integrated care and support that is person-centred, tailored to the needs and preferences of those needing care and support, carers and families.” (15.1)

Although integration, cooperation and partnerships in their own right is a theme in a number of significant sections of the Act, it is intended as a holistic piece of legislation and therefore integration relates to prevention, information and advice, and coordinating a shared approach towards the market – not just when someone has a specific care and support need. In making Safeguarding Adults Boards a legal requirement the Act underpins the principle that relevant organisations must work together in partnership beyond integration of services.

The Act and its accompanying guidance is also clear that integration, cooperation and partnerships are tools and processes for improving care and support, as compared to the desired outcome i.e. integration simply for its own sake, is meaningless; it is only relevant in the context of what it can achieve for end users and in terms of ensuring that the delivery of care and support is cost effective.

5. Key wordsThe suite of learning materials contains a glossary of key words used in the statutory guidance. The following key words, definitions of which can be found in the glossary, are relevant to this topic area: commissioning, cooperation, duty, information, integration, partnership, preventative, provider, rights, safeguarding, signposting, transition, wellbeing.

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6. IntroductionSlide 1

Notes1. This workbook forms part of the suite of learning materials that have been

developed to support the implementation of Part One of the Care Act 2014. These materials summarise and explain the ‘Care and Support Statutory Guidance’ (October 2014) and are designed to help those involved in care and support services to understand and implement the Act.

2. The presentation is about integration, cooperation and partnerships. It is intended for: those responsible for planning and delivering integrated care and support.

This would include lead commissioning staff in adult social dare, the CCG and in other elements of the local authority such as planning and housing

managers in adult social care and in other parts of the local authority, health services (including the acute trusts, private hospitals, ophthalmic and pharmaceutical services) and housing providers. This would include managers of local authority, private and voluntary sector service providers

those involved in the governance of these organisations, in particular elected members and others who may sit on Health and Wellbeing Boards

staff who are impacted by, or likely to be impacted by, greater integration, cooperation and partnership working and who wish to understand some of the legislative and strategic implications of the Act.

3. The aim of the presentation is to help people reflect on how and why adult social care needs to work with other bodies (and vice versa) if care is to be successfully delivered and supported, and the levers with which the Act enables organisations to work more collaboratively together.

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Slide 2

Slide 3

Notes1. The expectation on public bodies to work together is not new. There has been a

whole series of legislation, policy and guidance calling for better joint working between health and social care, dating back as far as 1973, when the NHS Reorganisation Act placed a statutory duty on health and local authorities to collaborate with each other through Joint Consultative Committees.

2. In 1997 ‘The New NHS: Modern, Dependable’ charged strategic health authorities to produce local plans for improving health, based on cooperation between health (PCTs as was then) and local authorities.

3. Cooperation between health and social care agencies was encouraged by the Health Act 19991, which placed a duty of partnership on the NHS and local authorities, along with powers to be able to develop lead commissioning arrangements, integrated provision and pooled budgets. These legislative flexibilities, that enable joint working, still apply under the Health and Social Care Act 2012

4. In 2005 ‘Independence wellbeing and choice’ called for better integration between social care and health (PCTs as was then) in order to deliver

1 Section 31 The Health Act 1999 as amended by section 75 the National Health Services Act 2006

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personalised care for individuals. Whilst in 2006 the National Health Service Act consolidated previous legislation and put in place arrangements to allow the NHS and local authorities to pool budgets.

5. The drivers for change have included2: Better access to services, more local provision and commissioning services

aimed at preventing or delaying care needs. Ensuring equitable access to services through needs based commissioning

and developing community based support systems. Harnessing the whole system to deliver better outcomes for people through

extensive needs and market analysis to shape the care environment, and the transformation of communities through high quality health and wellbeing services, infrastructure, housing, transport and education, training and employment opportunities.

6. In practice, however, this has often been difficult to achieve for a number of organisations due to historical and structural differences in the way they operate and commission services. The Care Act aims to clarify expectations and boundaries and enshrine the principle of joint-working in statute.

Slide 4

Notes1. Why are integration, cooperation and partnerships an important theme? Why is

there a new expectation placed on local authorities and partners to cooperate?

2. “Organisational barriers” and “having to repeat information” are complaints often levied at the health and social care system and can prevent people from accessing the types of care and support they need – when they need it.

3. The benefits of cooperation, partnership and integration are well documented by the likes of the Kings Fund and the Joseph Rowntree Foundation. A “joined up” or “whole-system” approach has been shown to deliver benefits to organisations, staff and, above all, service users.

2 Institute of Public Care, Oxford Brookes University (2010) From the Ground Up: A report on integrated care design and delivery. Department of Health, Integrated Care Network and Community Health Partnerships.

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4. Increased integration, cooperation and partnership working can: improve the service user experience – Coordinated and integrated care

makes sure the diverse and multi-faceted care system works as smoothly and efficiently as possible. There are benefits in this for organisations in terms of efficiency, for professionals in terms of effectiveness, but above all for service users in terms of a smooth, easily understood and responsive single experience.

eliminate duplication – Individual circumstances are not always neatly delineated against our own professional or organisational functions and a variety of professional disciplines (and organisations) can contribute to addressing the needs of an individual or community. Without a collaborative and coordinated approach, these frequently lead to confusion and duplication for the both the professionals supporting the person, and also the person involved. This is often wasteful of public resources and frustrating and disempowering for individuals and families. Better alignment and coordination can reduce the number of different inputs people receive and eliminate duplication.

streamline care pathways – As individuals or families develop the need for information, support and care, they will encounter a variety of agencies and professionals. They are required to navigate a journey, or “pathway” through the care system. If agencies collaborate effectively, then that pathway can be simplified and streamlined making easier it on the end user to access what they need.

earlier intervention and prevention – If agencies and professionals work together in a more structured way and draw together their collective knowledge and expertise, the needs - or potential needs - of individuals, communities and specific groups of people can often be identified earlier. This can offer the opportunity to those agencies and professionals to develop and implement coordinated responses aimed at preventing crises that lead to the need for intensive or long term care. Examples can include falls prevention programmes or reablement services which can also support the return of individuals to much greater levels of independence.

improve safeguarding - Partnership working improves responses to safeguarding alerts, outcomes and protection for adults who are at risk of harm or are suffering abuse. It also promotes a more joined-up approach to promoting an asset based approach to prevent abuse happening.

5. There are many different approaches to improving joint-working, and the Act presents three approaches – integration, cooperation and partnerships. We will come onto the detail of these in the following slides, but it is important to note that they are not the same (although they may have the same desired outcomes); that there are many different models of each; and that no one model is better than the

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other but that it should be chosen based on the agencies involved and the issues that greater joint working is designed to address.

Slide 5

Notes1. There are many definitions we can use to understand the difference between

integration, cooperation and partnerships. For the purposes of understanding the Act, however, we define: integration – ‘… as an organising principle for care delivery with the aim of

achieving improved user and patient care through better coordination of services provided. Integration is the combined set of methods, processes and models that seek to bring about this improved coordination of care’3.

cooperation – public organisations working together in partnership to ensure a focus on the care and support and health and health-related needs of their local population. The guidance refers to this as being a general principle for all those concerned and gives details on who should be involved and how this should happen4.

partnership - A joint working arrangement where the partners: are otherwise independent bodies; agree to co-operate to achieve a common goal; create a new organisational structure or process to achieve this goal; plan and implement a joint programme; share information, risks and rewards5.

3 Shaw,S., Rosen, R., and Rumbold, B. (June 2011) What is integrated care? An overview of integrated care in the NHS. Research report, Nuffield Trust.4 Department of Health (2014) Care Act Guidance.5 Audit Commission (1998) A Fruitful Partnership

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Facilitator’s hints and tipsConsider getting people to work in pairs to consider the differences between these terms and consider the following questions:

When would one approach be more suitable than another? Have you got examples? What are the challenges in each scenario?

7. What the Act says and the duties that fall to local authorities

Slide 6

Notes1. The requirement on local authorities to cooperate with others, and to ensure

partnership and integration is a theme throughout the Act and much of it cannot be achieved without authorities considering how they should work with other organisations to deliver care and support.

2. The key sections for local authorities are: section 3 – the duty to share care and support responsibilities through greater

integration with health services section 6 – the duty to cooperate with each of its relevant partners. In turn,

each relevant partner must also cooperate with the authority, in the exercise of their functions relating to adults and carers

section 7 – with regard to the care and support needs of an individual and/or carer, this section places a duty on the local authority to cooperate and on a “relevant partner” to cooperate in meeting care and support needs

sections 22, 23 and 74 lay down some of the boundaries to local authority provision in relation to health and housing services, whilst Schedule 3 relates to hospital discharge

section 43 - the duty on each local authority to establish a Safeguarding Adults Board for its area comprising of itself, the NHS and the police as core members, plus other relevant partners, with the objective of working together

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to help and protect adults by co-ordinating and ensuring the effectiveness of what each of its members does.

Questions What key words or phrases (on the slide) stand out to you? Why? What might your local authority need to do to improve the way it works with

partners to improve adult safeguarding?

8. The duty to promote greater integration

Slide 7

Notes1. The necessity and benefits of integration are summed up in this sentence taken

from the statutory guidance which accompanies the Act.

2. The Act seeks for the first time to place a legislative duty on local authorities to ensure citizens experience person-centred care, which is delivered through greater integration.

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Slide 8

Notes1. Section 3.1 of the Act defines the circumstances under which the duty to ensure

integration applies: to promote the wellbeing of adults with care and support needs and carers to contribute to the prevention or delay of support needs to improve the quality of care in its area local authorities must carry out their care and support responsibilities with the

aim of promoting greater integration with NHS and other health-related services (for example, housing or leisure services).

Slide 9

Notes1. It is important to note, that the Care Act also reflects similar duties on NHS

England and the Clinical Commissioning Groups (CCG) outlined in the Health and Social Care Act 2012.

2. Under this provision, this means NHS England must encourage partnership arrangements between CCGs and local authorities where it considers this would ensure the integrated provision of health services and that this would improve the quality of services or reduce inequalities.

3. Similarly, every CCG has a duty to exercise its functions with a view to securing health services that are provided in an integrated way, where this would improve the quality of health and/or reduce inequalities in access or outcomes.

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Key learning pointThe Act places an expectation on local authorities to understand and deliver the benefits of integration in partnership with other organisations such as the NHS. This is reciprocated under the Health and Social Care Act 2012.

Questions What additional levers for change and integration do you feel the Care Act

offers you in planning services to improve wellbeing? Can you identify any potential services in your area or team, where greater

integration could mean more person-centred care that promotes wellbeing, prevents or delays the development of needs and improves the quality of care?

9. The duty to cooperate

Slide 10

Notes1. Alongside the requirement to integrate provision there is also a wider duty of

cooperation with a range of services. For example, the police or children’s services, and local offices of the Department of Work and Pensions. This is both in terms of a general duty to cooperate as well as a duty to cooperate in relation to the specific circumstances of individuals or carers6 and as such is a general principle to all those concerned. It also opens up opportunities for local authorities – where appropriate – to work with other organisations such as independent and private providers through a range of contractual agreements.

6 Sections 6 and 7 of the Act

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2. In Section 6 the Act sets out five aims of cooperation between partners which are relevant to care and support, although it should be noted that the purposes of cooperation are not limited to these matters: “promoting the wellbeing of adults needing care and support and of carers; improving the quality of care and support for adults and support for carers

(including the outcomes from such provision); smoothing the transition from children’s to adults’ services; protecting adults with care and support needs who are currently experiencing

or at risk of abuse or neglect; identifying lessons to be learned from cases where adults with needs for care

and support have experienced serious abuse or neglect and applying those lessons to future cases.”

3. The Act and its associated guidance is quite clear on this issue. Local authorities and their partners must cooperate when exercising their respective functions relevant to care and support. That cooperation can be achieved through various means and that some actions may actually overlap with those associated with integration (for instance, pooled budget arrangements or information sharing).

4. Note that the Act gives the lead on safeguarding to local authorities but they will largely achieve this through Safeguarding Adults Boards (SAB). The Act sets out changes to SABs' responsibilities to commission Safeguarding Adults Reviews more flexibly to identify lessons to be learned from cases where adults with needs for care and support have experienced serious abuse or neglect and applying those lessons to future cases.

Slide 11

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Notes1. Under the Act local authorities have a duty to cooperate with a number of

statutory organisations, including the NHS, other local authorities, the Department of Work and Pensions, the Police, and Prison and Probation services, as well as other local authorities (for example district councils or other authorities arranging care for a person in the area). These organisations also have a reciprocal responsibility to cooperate and any failure to do so would constitute a breach of the Act.

2. However the guidance makes clear it is also not just cooperation between the local authority and other statutory agencies, but also cooperation within the local authority which is essential to delivering care and support – such as housing, trading standards, children’s services and public health - the corporate responsibility of elected members towards the safety of adults at risk of harm applies. Local authorities may also want to think about how transport, planning and leisure contribute to the wider wellbeing agenda.

3. The local authority may also wish to consider other persons or bodies that would be appropriate to cooperate with. These may include the independent or private sector and can include providers, voluntary organisations and the Care Quality Commission. The extent to which local authorities choose to cooperate with these organisations would need to be explored in depth, however, and mechanisms would need to be put in place to ensure there was mutual cooperation from all parties through the use of contracts and other means.

Key learning pointThe Act specifies the public bodies that the local authority must cooperate with, and that these bodies must reciprocate.

Questions

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What arrangements does your local authority have in place to ensure that the five aims of cooperation between partners which are relevant to care and support, can be delivered?

How effective are these? What other organisations might you consider cooperating with in the future?

Slide 12

Notes1. Cooperation as described in the Act and guidance does not just relate to the

general duty to cooperate, but also to a duty in respect of individual cases. These cases may include safeguarding enquiries; the move of an individual from one area to another where both authorities involved need to cooperate; or where the assessment of care and support highlights other specific needs such as a continuing healthcare eligibility.

2. In practice, many of the arrangements that will either already be in place or put in place in response to the Act will address most instances relating to specific cases. However, this part of the Act does enable local authorities – and their partners – to ask for (and expect) cooperation in individual cases unless it is incompatible with their own duties or have an adverse effect on the exercise of their functions.

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3. It is designed particularly for those cases where targeted cooperation is required and where a more tailored responses is necessary.

4. If this mechanism is needed either the local authority or the partner requesting cooperation should notify the other in writing making it clear that this is under their duty to cooperate in specific cases under the Care Act.

5. The guidance is clear that any failure to respond within a reasonable timeframe could be considered a breach and subject to a judicial review.

6. A Safeguarding Adults Board can demand information from persons or agencies where: the request is made for the purpose of enabling or assisting the SAB to exercise its functions and the Board considers that the person is likely to have such relevant information.

Key learning pointPartner organisations must cooperate with specific requests for cooperation from the local authority in relation to particular individual cases, unless doing so would be incompatible with the partner’s own functions or duties. The converse also applies.

QuestionsCooperation in specific cases enables partners to request cooperation from other public sector organisations:

Under what circumstances might you need to use this duty? Can you think of a time when doing so might prove incompatible with your

own organisations functions or duties?

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10. Integration, cooperation and partnerships in practice

Slide 13

Notes1. Integration, cooperation and partnerships need to be seen as a key component of

a local authority’s strategic approach for improving care and support.

2. National Voices and the Making it Real initiative have identified the core elements of good integrated care, through the development of a series of ‘I statements’ exploring the service user perspective and producing a narrative for the basis of all integrated care and support. These statements challenge organisations to ensure that service users and their carers experience care where “…care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes”.

3. The Care Act puts in place the legislative framework to enable local authorities to do this by working closely with other organisations – either in partnership or through more formal integrated mechanisms. It also challenges the authority to work more closely across its own functions such as social care, leisure, planning and housing.

4. The mechanisms by which the authority may do this can include planning and commissioning – through joint commissioning teams, or aligning plans and strategies; joint assessments and information, advice and guidance; integrated care delivery; and joint or integrated quality assurance mechanisms.

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Slide 14

Notes1. The Care Act is quite clear, integration and cooperation must be delivered in the

context of improving care and support, and in line with promoting wellbeing and the quality of care.

2. At a minimum this should include local authorities seeking to integrate or cooperate with services such as health and the NHS, housing, and those relating to individual employment, training and educational needs .

3. There is an expectation that public sector organisations will cooperate in return, and - in the case of the NHS – there is a reciprocal duty placed on any NHS body within the local authority’s area including clinical commissioning groups, hospital trusts, and NHS England.

4. Existing mechanisms for pooling budgets such as section 75 and the Better Care Fund can help to implement greater integration.

Facilitator’s hints and tipsEither in pairs or as small groups, get the group to consider:

examples of integration and partnership working that they have experienced what has worked well, or not so well? bearing in mind the definition of integration from the service user perspective

(National Voices/Making it Real) how could their own approaches be improved?

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Slide 15

Notes1. The limits of the local authority in relation to providing healthcare have not

changed under the Care Act 2014.

2. Local authorities must carry out an assessment where someone appears to have need for care and support. They have a duty to meet those needs for care and support that meet the eligibility criteria.

3. Under Section 42 the local authority must make enquiries, or ensure others do so, if it believes an adult is subject to, or at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to stop or prevent abuse or neglect, and if so, by whom. If the enquiry results in recommendations for provision of services to stop or prevent abuse then the local authority must provide them regardless of the eligibility status of the person.

4. Section 22 of the Care Act sets out the limits on what a local authority may provide by way of healthcare and so, in effect, sets the boundary between the responsibilities of local authorities for the provision of care and support, and those of the NHS for the provision of healthcare.

5. Local authorities cannot lawfully meet needs by providing or arranging services that are clearly the responsibility of the NHS. The two most obvious examples that are clearly the responsibility of the NHS are where the individual is eligible for NHS Continuing Healthcare, or NHS-funded nursing care.

6. Occasionally the local authority may provide some limited healthcare as part of a package where it is “incidental and ancillary”, which means where the healthcare component is only a minor part of a broader package being commissioned or delivered, and where the services are the type of support that an authority whose primary responsibility if to provide social services could be expected to provide.

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7. Effective joint working in these cases will require organisations to be clear about care pathways, handovers and the contribution local authorities and health organisations make to care.

Slide 16

Notes1. The Act and its accompanying guidance also deal with hospital discharge where

a person may have care and support needs.

2. The provisions on the discharge of hospital patients with care and support needs are contained in Schedule 3 of the Care Act 2014 and the Care and Support (Discharge of Hospital Patients Regulations 2014). These provisions aim to ensure that the NHS and local authorities work together effectively and efficiently to plan the safe and timely discharge of NHS hospital patients from NHS acute medical care facilities to local authority care and support. Schedule 3 covers: the scope of the hospital discharge regime and the definition of the patients to

whom it applies the notifications which an NHS body must give a local authority the period for which an NHS body can consider seeking reimbursement from

a local authority, where that local authority has not fulfilled its requirements to assess or put in place care and support to meet needs.

3. The provisions also shouldn’t be seen in isolation. Many of the discharge issues are attributable to the NHS and are within their gift to address, but equally there are opportunities for local authorities and the NHS to work together to improve performance on delayed discharge. Whilst general duties to cooperate and integrate services should also encourage improved performance in this area. The Better Care Fund is one such example.

4. The requirements for discharge provision however, do not apply to: mental health care where the arrangements are the primary responsibility of a

consultant psychiatrist. If however, the individual is within an acute care setting, but with mental health care needs, because they are under the care of

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an acute medical consultant the case could fall within the scope of these discharge arrangements

patients with palliative care needs private patients unless they elect to change their status and become NHS

patients

other types of care such as maternity care, intermediate care and care provided for recuperation or rehabilitation.

5. However, it is worth noting that patients who receive acute treatment arranged and funded by the NHS, but within a private hospital setting are covered by the provisions for discharge within the Act.

Key learning pointLocal authorities and the NHS need to be clear about the boundaries between care and support and the NHS. They should work together to improve delayed transfers of care, and there are opportunities to do so in the Act, guidance and Better Care Fund.

Questions What are the key implications of the Act on the way you currently work across

health and social care to plan and manage discharge from hospital? How might you work better together to improve performance around DTOCs?

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Slide 17

Notes1. Suitable living accommodation plays an integral part in meeting the aims of Care

Act, particularly if local authorities are to meet the challenges it poses around promoting physical and emotional health and wellbeing.

2. Housing is seen as a means to enable people to live independently and should be safe and secure, supporting people to build full and active lives. In terms of the wider social care market and the wellbeing principle cooperation with housing relates not only to the provision of accommodation but the range of housing related services, such as housing adaptations, supported living and social and private registered providers.

3. In terms of prevention the right housing can: help prevent falls – by improving accessibility or through the provision of aids

and adaptations reduce ill health - through good quality heating or through integrating assistive

technology into design of housing schemes reduce social isolation – through facilitating better contacts with neighbours

and through people feeling safe speed up hospital discharge – by having safe accommodation into which a

range of health and support services can be delivered reduce and prevent adult abuse - by increasing awareness of its possibility

among housing providers so potential risks are spotted earlier and more people know how to respond if they suspect a person is being abused

enable people with dementia or with visible impairments to remain in the community longer – through housing design that lessens the impact of these conditions

reduce costs – through design that saves on energy bills and reduces maintenance.

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4. Given this, the Act and its guidance are clear that local authorities must work with housing authorities and providers. It will also require considerable work within the authorities across social care and planning to ensure that opportunities to develop the right type of housing stock to meet needs, promote wellbeing and prevent or delay care needs developing are in place over the longer term.

5. Local authorities also need to make sure that people have access to information and advice on housing and housing-related support. For example local authorities should provide information on: the range of services that are available to people in their own homes where to obtain advice about different types of supported housing (state,

voluntary and private) what to look for in assessing a sheltered housing, extra care or residential

care scheme how to get help with moving, or with maintaining a property financial advice on different care options that may be available.

Key learning pointHousing is seen as an integral part of improving wellbeing and in delivering care and support. Local Authorities are expected to work closely with housing providers and planning departments.

Questions Based on your own experience and knowledge, what ways can housing

improve care and support? How might your organisation work more closely with housing providers in your

area to improve wellbeing? What steps would you need to take to achieve this?

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Slide 18

Notes1. Employment, training and education form a fundamental part of the wellbeing

principle and as such local authorities must consider whether participation is relevant when they are promoting individual wellbeing.

2. This has a number of implications for how assessments are conducted and how local authorities and their partners (for example, the Department of Work and Pensions local offices (e.g. JobCentre Plus), children’s services, and colleges) work together.

3. For example: when carrying out a needs assessment, carer’s assessment or child’s carer’s

assessment, local authorities must have regard to whether the carer works or wishes to do so, and whether the carer is participating in or wishes to participate in education, training or recreation

sections 37 and 38 of the Act support people to move areas, including to pursue employment opportunities or move closer to family members. Local authorities must ensure continuity of care and support when people move between areas so that they can move without the fear that they will be left without the care and support they need.

4. Finally local authorities must ensure that good quality information and advice on employment, training and education opportunities is available, and that there is a good mix of providers available to support people with these needs.

5. The Act also makes provision for local authorities, working with their partners, to make use of the wider opportunities to provide targeted information and advice at key points in people’s contact with the care and support, health and other local services. This should include application for disability benefits such as Attendance Allowance and Personal Independence Payments, and for Carers Allowance and access to work interviews.

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11. Working together: examples

Slide 19

Notes1. In conjunction with other legislation the Act paves the way for greater joint

working across and within Local Authorities, public sector organisations and other organisations with care and support functions as appropriate.

2. Therefore whilst the Act sets out explicitly its minimum expectations in relation to discharge planning, working with housing and employment, education and training, it also offers the chance to build on existing responsibilities and to explore new opportunities through: strategic Planning by building better commissioning arrangements or joint

commissioning teams commissioning integrated services, or jointly commissioning specific

services such as advice and advocacy services assessments and information such as integrated health, care and housing

assessments delivery or provision of care via integrated community teams, or working

with housing providers to ensure that adaptations support independence, reablement or recovery.

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Slide 20

Notes1. Strategic planning is the set of activities by which the Local Authority works with

its partner organisations, own departments and – where appropriate - providers to ensure there is enough provision of services, housing, and facilities to meet the needs of its local population. Through this there are a number of tools by which Local Authorities can develop greater collaboration, cooperation and integration and in the case of care and support services these include: Joint Strategic Needs Assessments Joint Health and Wellbeing Strategies Local Development Frameworks Market Position Statements, and Joint functions such as joint commissioning or procurement teams.

2. However, the statutory guidance notes that strategic planning on its own “…will not be sufficient to fulfil the requirement to promote integration; it will be the agreed actions which follow the strategies and plans that will have the greatest impact on integration and on the experience and outcomes of people” (15.10). How local authorities respond to the analyses and commitments laid out in their assessments and strategies will be crucial to the successful implementation of the Act.

Questions How effective are your current approaches to strategic planning? Are there opportunities within the Act to improve cooperation and

collaboration across the key agencies? What steps could you take to improve how well your plans are put into

practice?

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Facilitator’s hints and tipsDepending on the group you are working with you might want to consider how challenging you can be with these questions. For example the questions could be used to:

support strategic commissioners and senior managers to reflect on how well their planning and commissioning arrangements meet the needs of their local populations

offer operational managers chance to understand how their service responds to the challenges facing them in their strategy and plans and whether the plans currently offer them enough information on which to base decisions about the shape and type of services on offer

challenge partners to reflect on what works well currently and what could be improved.

Slide 21

Notes1. There are a number of ways in which local authorities can respond to the Care

Act and ensure that services are more integrated where possible. Alongside strategic planning, commissioning is one tool available to deliver this and there are a range of models available to organisations to consider. You may find it helpful to think of collaborative commissioning on a spectrum of four levels of ‘jointness’. Separate Approaches: Where objectives, plans, actions and decisions are

arrived at independently and without coordination. Parallel Approaches: Where objectives, plans, actions and decisions are

arrived at with reference to other agencies. Joint Approaches: Where objectives, plans, actions and decisions are

developed in partnership by separate agencies. Combined Approaches: Where objectives, plans, actions and decisions are

arrived at through a single organisation or network.

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2. Some examples are given of commissioning activities, in this table, to illustrate separate, parallel, joint or integrated approaches.

3. Regardless of the route chosen the Nuffield Trust offers a helpful checklist to good practice7. Recognise that planning and implementing large-scale service changes takes

time. Define the intervention clearly and what it is meant to achieve and how, and

implement it well. Be explicit about how desired outcomes will arise and use interim markers of

success. Generalisability and context are important. What works in one context may

not work in another. If you want to demonstrate statistically significant change, size and time

matters. It is important at the outset to decide what level of evidence and findings are going to be necessary to show that the approach works.

Pay attention to the process of implementation as well as outcome. Carefully consider the best models of evaluation. Work with what you have. Organisation and structural change may not deliver

outcomes.

4. Commissioners may also want to consider using pooled budgets to commission jointly agreed services and minimise overlap/gaps in service delivery, increase efficiency and improve value for money.

Question Reflecting on the collaborative commissioning spectrum, which

commissioning activities do you currently do separately, in parallel, jointly or combined? Where are you now as and where do you want to be?

Thinking about the implications of the Care Act in relation to promoting wellbeing, preventing or delaying the need for care and developing high quality services: What approaches to commissioning might best help you achieve these? What could you do differently?

7 Evaluating integrated and community based care – How do we know what works? Nuffield Trust, June 2013.

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Slide 22

Notes1. The statutory guidance suggests that an integrated approach can most fruitfully

be taken by having a joint information and advice service (covering health, care and housing) which links assessments with advice and information on, among other issues, housing and finance.

2. This may include integrating an assessment with information and advice about housing, care and related finance to help develop a care plan (if necessary), and understand housing choices reflecting the person’s strengths and capabilities to help achieve their desired outcomes.

3. There may be occasions where a housing staff member knows the person best, and with their agreement may be able to contribute to the assessment process or provide information.

4. An integrated assessment process covering health, social care and housing needs will allow for a clearer picture of the person’s needs holistically, and for a single point of contact with the person to promote consistency of experience, so that provision of different types of support can be aligned.

5. Local authorities have powers to carry out assessments jointly with other parties, or to delegate the function in its entirety. A number of local authorities together with community health services have been developing joint assessments for some time. The key benefit to end users is through cooperation by services knowing what each is doing and also through not having to repeat the same story several times.

6. The guidance makes it clear that even if joint assessment is not possible this does not lessen the need to cooperate.“….combining assessments may allow for a clearer picture of the person’s needs holistically, and for a single point of contact with the person to promote consistency of experience, so that provision of different types of support can be aligned. A number of assessments could be carried out on the same person, for example a care and support needs assessment, health needs assessment and continuing healthcare assessments.

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Where it is not practicable for assessments to be conducted by the same professional, it may nonetheless be possible to align processes to support a better experience, for example, the 2nd or 3rd assessor could be obliged to read the 1st assessment (provided there is a lawful basis for sharing the information) and not ask any information that has already been collected, or the different bodies could work together to develop a single, compatible assessment tool. Local authorities have powers to carry out assessments jointly with other parties, or to delegate the function in its entirety”. (15.14)

7. At the individual level, initiatives to promote the integration of care and support could include recruiting and training individual care coordinators who are responsible for planning how to meet an adult’s needs through a number of service providers. Another example could be in relation to working with people who are being discharged from hospital, where staff from more than one body may be involved with providing or arranging care and support to allow the person to return home and live independently.

8. Although not explicitly described in the Act, regulations or guidance, integration is also a significant concept for carers given that virtually the entire Act applies to individuals, who may or may not be in receipt of care and support, also applies to carers. They should be able to experience ‘joined up’ provision equally as much as the person or persons they look after. This may manifest itself in a number of ways: information for carers that helps them to remain in employment whilst carrying

out caring responsibilities fast track healthcare provision that enable carers to access health resources

without neglecting the person they are caring for information about the health and care concerning particular conditions such

as dementia or at particular times such as the diagnosis of a learning disability that enables people to consider the implications of the caring role.

9. However, integration for many carers also means being seen as part of a care and support service rather than their role being taken as read or as subservient to paid for care. Therefore, whilst carers are entitled to their own assessment and different help and support from the person they care for, they also need to be seen as significant providers of care or as partners in a range of provision and hence one where their offer needs to be integrated with that of others.

Key learning pointThe key benefit to end users is through cooperation by services knowing what each is doing and also through not having to repeat the same story several times.

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Questions What steps do you think could be taken to combine or align key processes in

the care and support journey in your locality?

Slide 23

Notes1. In terms of its work with the care market the Act provides the legislative

framework for local authorities to consider how they can commission integrated services from providers to improve the quality of care for people.

2. Integrated services must be seen to be offering real change within the system, addressing service user needs and becoming more person-centred in order to meet the aims of the Act.

3. There is considerable research and guidance into what constitutes good integrated care and how to implement it, but this still remains a challenge for many authorities and provider organisations.

4. The recent National Voices and Making it Real “I statements” build the narrative for integrated care and are increasingly being used as the basis for modelling services. They challenge commissioners and providers to ensure that care is: “planned with people who work together to understand me and my carer(s),

put me in control, co-ordinate and deliver services to achieve my best outcomes”.

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5. Services which could be more integrated could include community teams, reablement services, and housing with care services. They should not be limited to just one group of service users and Local Authorities will be expected to work with their partners to think creatively about how they can better align, integrate and cooperate to develop more person-centred care.

6. This should draw on the full remit of duties under the Act, from assessment, information and advice through to market shaping and commissioning and – in some cases – may require a fundamental rethink in how care is delivered.

Key learning pointIntegration must be seen as an opportunity to improve the quality and provision of care for the service user and their carer. It must be outcome focussed and may mean significant changes in the way care is commissioned and provided.

Questions What local services do you think would benefit from more integration at the

frontline and why? What would be the challenges?

Facilitators hints and tips:Use the National Voices and Making it Real statements to base discussions on how services might need to change and become more integrated in order to deliver care and support which fulfils these statements.Consider using models with your groups, to understand how holistic integrated care can be shaped and delivered, examples include:

The Institute of Public Care (2010) From the Ground Up: A report on integrated care design and delivery

The Centre for Workforce Intelligence (2013) Think Integration: Think Workforce

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12. Summary

Slide 24

Notes1. The Care Act provides the legislative framework for greater integration,

cooperation and partnership working across health and social care, and other relevant partners in the delivery of care.

2. It is intended to be a holistic piece of legislation which encourages local authorities and their partners to think about wellbeing in order to deliver quality care designed to meet the needs of individuals.

3. Local authorities and their partners will have a duty to cooperate, and a duty to integrate services where there is a perceived benefit for wellbeing; or where integration, cooperation and partnership working can contribute to the delay or prevention of the development of care needs; or where the quality of care and support can be improved.

4. The local authority is not solely responsible for promoting integration and cooperation. Similar duties are also placed on the NHS under the Health and Social Care Act 2012. Other public sector organisations are also expected to cooperate including the Police, Prison and Probation services and local authorities may also seek cooperation from other organisations or bodies if it considers this appropriate when exercising care and support functions. These could include care and support providers and primary care providers.

Questions What has struck you most about this session? Thinking about what you have learnt about this topic area (and on any other

modules you have completed so far)....... What links can you make between topic areas? How might the necessary changes impact on your current arrangements? What might the key challenges be?

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Exercise What are your top three priorities in relation to integration, cooperation and

partnerships? Complete the action plan to identify the next steps for each priority.

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AppendicesLinks to key resourcesThe Kings Fund (2013) Making use of the Better Care Fund: spending to save? The creation of the £3.8 billion Better Care Fund offers a real opportunity to lay the foundations for a much more integrated system of health and care. This paper summarises the evidence from work by The Kings Fund and other research about which approaches are likely to offer commissioners maximum impact in a way that will benefit both the NHS and social care.

The Kings Fund (2014) Integrated Care and Partnership Working Reading List

NHS England Better Care Fund Planning Available at http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/ (Accessed 29 August 2014).

Nuffield Trust (2013) Commissioning High-Quality Care for People with Long-Term Conditions

Sara Shaw et al (2011) What is integrated care? A review of integrated care in the NHS. Nuffield Trust. This research report examines what is meant by 'integrated care'. It explores integrated care from an NHS perspective, identifies the concepts that underpin integrated care, suggests how these can be used to inform practical integration efforts both within and beyond the NHS, and sets out how integration might be measured.

Think integration, think workforce: three steps to workforce integration, Centre for Workforce Intelligence (2013). The paper identifies three steps for workforce leaders to promote integration from a workforce perspective:

Be clear about the local integration agenda, including the various routes to integration.

Address the integrated workforce management challenge to ensure the right people with the right skills and behaviour are in place to deliver integrated services around individuals’ needs.

Implement successful workforce change by addressing a range of operational and strategic questions by taking an inclusive approach.

6.

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National Voices, a national coalition of health and social care charities have produced a narrative for person-centred, co-ordinated care and support, More details can be found here: http://www.england.nhs.uk/2013/05/14/c-care/

Four Nations United: Critical learning from four different systems for the successful integration, ADASS (2013). Draws upon practice and research knowledge and outlines the critical factors found within successfully integrated practices and the contribution of social services to this work. It aims to provide staff across key services with an informed, sophisticated but accessible and practical ‘ready reckoner’ of best approaches to the challenge of successful integration – a short cut to increased capacity and improved performance.

The integration clauses mirrors similar duties placed on Clinical Commissioning Groups and NHS England. There are a number of relevant documents that local authorities may find of interest:

The Functions of Clinical Commissioning Groups, NHS England March 2013

Statutory Guidance on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies, Department of Health, April 2012. See part 4: Promoting integration between services.

The following links provide further sources of information in relation to housing service and practical examples which support integration with care and support on a local level:

http://www.housinglin.org.uk/Topics/browse/Housing/hwb/? parent=3691&child=8169

http://www.cih.org/publication-free/display/vpathDCR/templatedata/cih/ publication-free/data/Developing_your_local_housing_offer_for_health_and_care

https://www.gov.uk/government/collections/housing-health-and-safety-rating- system-hhsrs-guidance

http://www.housinglin.org.uk/hospital2home_pack/