In health and social care, integration of services occurs where agencies involved with patients at different stages of the care pathway are, or become part of, a single organisation, e.g. the structural integration of primary, community and secondary care achieved by hospitals expanding their scope. With the introduction of statutory registration for paramedics and the advancement of graduate entry in 2003, it could be suggested that it was at this stage that recognition of the paramedic profession occurred. Ambulance services in the UK have moved away from being a part of secondary care, with the establishment of much stronger links within and with the primary care sector. Along with this came developments in the role of the paramedic, moving away from a focus on the transportation of patients and the provision of first aid, to the assessment and treatment of people presenting with a wide range of trauma and medical conditions.
Ambulance services in the UK have continued to develop and shape the contribution that they make to the National Health Service (NHS). They have adapted and adjusted the services that they provide, ensuring that they do not offer commissioners more of the same. Services have been redeveloped to make sure that they align with current policy, putting the patient and the public at the heart of the health and social care system (Department of Health (DH), 2010).
The primary aim of the government's NHS reforms that were set out in the Health and Social Care Act 2012 (c.7) is to create a more patient focused NHS, permitting clinicians and frontline staff to have a far greater role in organising and commissioning care, as well as providing it. Ambulance services are (currently) somewhat unaffected by the new organisational changes that have come about as a result of the Act; they will, for the moment at least, carry on being the core emergency response.
‘An integrated approach would put an end to how patients and their families currently feel being pushed from pillar to post in a disjointed service’
In England the NHS reforms are now being acted out and are becoming more embedded. It will be essential that those clinicians who are leading the clinical commissioning groups (CCGs) become involved in ambulance commissioning; for this to happen effectively commissioners will need to have an understanding of the role and significance of ambulance commissioning so that a safe and effective ambulance service can be maintained as part of a high-quality urgent and emergency care system (NHS Confederation, 2012).
The magnitude of the NHS reforms currently being implemented is significant. The transforming of urgent and emergency care services is key to realising the government's intentions of improving outcomes that are delivered by the NHS, together with the delivery of greater efficiency and productivity.
Integrated services involve the NHS (the ambulance service), patients, families and local councils. When a person requires the services of the NHS, often service providers fail to come together to support the person and their families. People need and expect the right support, on time, delivered by well-educated professionals, and this could be the NHS or a local council. The situation is that families and carers may feel that they are being passed between and around the different professional groups and bureaucracies, and this can often seem to patients and their families that none of them are taking any responsibility. As a result of the maze of bureaucratic administration, patients are often not seen as decision makers and are frequently left wandering around aimlessly through a confusing web of health and care systems, being removed from the decision-making process.
Patients and their families are often complimentary about the individual care and support paramedics, nurses, doctors, social workers and care assistants provide, but they feel that health and social care services work for the system and not for them. An integrated approach would put an end to how patients and their families currently feel being pushed from pillar to post in a disjointed service.
‘Services can only work together effectively if each group has an understanding and appreciation of what the others do’
The government has announced plans for ‘joined-up’ health and social care by 2018, with the possibility of imposing financial penalties on services if patients reveal that they have had to retell their stories to different layers of professionals over and over. The Mid Staffordshire and Winterbourne View investigations have demonstrated the significance of the NHS and social care services working in unison, being open and transparent, and responding with clarity to the people who use services. Providing the best care is about listening to and respecting the wishes of families as they work through the system. When patients have to retell their story every time they encounter a new service then this demonstrates that we are not listening to them. The system is failing and people are not getting the support they require, as the various parts of the system are not communicating with each other. The current ways of working (policy and regulation) are barriers to delivering effective coordinated care. Barriers include competition law, IT systems and how to manage the pooling of savings made between the various organisations; these are not unsolvable barriers. Importantly, they should not be seen as barriers that justify inertia.
A transformational change is required where there is a move to a more integrated system, with care provision that is joined up and planned around the individual needs of the person. Working together with families and local councils (in an integrated manner) will improve outcomes and put the patient at the heart of all we do, every single person should be treated with compassion and with the respect they deserve. Care and support that is built around the needs of the individual, their carers and family will enable us to get the most out of every penny that is spent (National Collaboration for Integrated Care and Support, 2013).
There is much to applaud in the government's proclamation that there will be concerted efforts to integrate health and social care; however, with progress comes challenges. Integration will not be easy, it will be time consuming, challenging and expensive, there is no new money, and investment will have to be funded by efficiencies or cuts, let this not be forgotten.
The health reforms promote integration by bringing the key players together at health and wellbeing boards. The health and wellbeing boards are the best place for this to happen as they provide a forum where strategies can be decided and data brought together; those working in the different parts of the system are in one place with an overview, as well as understanding the perspective and value of others.
‘ Failing to understand the implications of this approach to care provision could leave the paramedic at a disadvantage’
The ambitious plans in place, and those being considered to ensure that all care services can come together, requires a strong commitment to identifying and overcoming the obstacles by all who provide services, including the statutory and voluntary sectors. All aspects of the care system will be required to take part in and make progress.
Services can only work together effectively if each group has an understanding and appreciation of what the others do, how they work and have some understanding of the care options and implications. Having a shared understanding, an understanding of the unique and shared cultures of the various service providers is essential. Investment must be with people, as opposed to the systems.
When integration of care occurs this can remedy the problem, as it leads to service providers (including the ambulance service) to work as a unit as opposed to different disparate entities. Integrated care ensures that those who are in need of our services receive seamless care irrespective of their situation. Integration in the truest sense cannot happen unless we respect and involve patients and their families, families are the biggest providers of care in the country.
As integrated care pathways gather momentum paramedics will not be untouched by these initiatives. Failing to understand the implications of this approach to care provision could leave the paramedic at a disadvantage. Integration also impacts on all aspects of the role and function of the paramedic, bringing with it a number of risks and also opportunities that are and will become more apparent during this period of transition, embedding and beyond.