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An Exploration of Health and Social Care Service Integration in a Deprived South Wales Area Wallace, C.A

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An Exploration of Health and Social Care Service Integration in a Deprived South Wales Area Wallace, C.A An exploration of health and social care service integration in a deprived South Wales area Wallace, C.A. Submitted version deposited in CURVE June 2011 Original citation: Wallace, C.A. (2010) An exploration of health and social care service integration in a deprived South Wales area. Unpublished PhD Thesis. Coventry: Coventry University in collaboration with the University of Worcester. Copyright © and Moral Rights are retained by the author. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This item cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder(s). The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. Three diagrams, including an ethics approval letter from appendix 11, have been removed due to third party copyright. The unabridged version of the thesis can be viewed at the Lanchester Library, Coventry University. CURVE is the Institutional Repository for Coventry University http://curve.coventry.ac.uk/open ‗An exploration of health and social care service integration in a deprived South Wales area‘ Volume 1 Carolyn Ann Wallace A thesis submitted in partial fulfilment of the requirements for the Degree of Doctor of Philosophy December 2009 Coventry University in collaboration with the University of Worcester Acknowledgement I have met numerous people along this journey who have contributed towards the development of my knowledge of research and integrated care. First of all I would like to thank the service users, carers and staff who participated in this study for their honesty and willingness to make their most valuable contribution. I would also like to thank the following: Prof. Dominic Upton, thank you for your support, but most of all for inspiring me to undertake this challenge many years ago. To all my colleagues, thank you for your support especially during the last six months. The University of Glamorgan and Gwent Healthcare NHS Trust for funding my academic development. To Michelle Davies for helping me gain the confidence to write our book and consolidate my learning of that aspect of integrated care. To Peter Wiggin for our Welsh Assembly Government research on Luncheon clubs which gave me an opportunity to test my thoughts on the methodology and methods used within this study. To Dr David Rowe for teaching me quantitative analysis. My colleagues at WIHSC, thank you for including me in the ‗Independent Review of Delayed Transfers of Care‘, ‗Care at Home‘ and WIISMAT (Wales Integrated Indepth Substance Misuse Assessment Tool) over the last 5 years. These were valuable contributions to my research development. In particular I would like to thank Prof. Marcus Longley, Prof. Tony Beddow, Prof. Morton Warner and Nick Gould not only for sharing their knowledge but for listening and debating the issues with me. I would like to thank my family, most particularly my husband Derek and daughters Rhiannon & Catrin for their love, support, humour and patience whilst I‘ve undertaken this academic marathon. Finally I wish to thank Bernadette Kelly for her contribution towards my academic development over the last 18 years and most recently for reading and formatting this work. This piece of work is dedicated to the memory of Glenys Margaret Williams SRN. Abstract Frailty poses a complex challenge for some people through their experience of ageing. In Wales, devolution requires organisations to use a whole systems approach with a model of partnership to deliver public services. An integrated care approach is offered to meet the service user focus or ‗value demand‘ which impacts on clinical, professional, organisational and policy levels within the system. Therefore, the aim of this study was to explore whether there was a difference between integrated health and social care day services and non- integrated health and social care day services. In doing so, answering the questions, how were these services different, what were the differences as perceived by the participants, why were they different, what could be learned from this study and how could health and social care services integrate in practice? The study utilized Gadamer‘s interpretative hermeneutics with a single intrinsic case study design. Using this approach ensured that the unique voice of the individual lived experience was heard and interpreted within the whole system of the study. The participants were service users, carers and staff in a day hospital, an outpatient clinic, day centre, reablement team and a joint day care facility. The methods included a survey questionnaire (SF12v2 and London Handicap Scale), in-depth interviews, observations; and historical and service documents; and reflective diary. Data collection occurred January 2005 to December 2006. Quantitative and qualitative data were analysed separately. The qualitative data was analysed using Gadamer‘s five stage approach developed by Fleming et al (2003) and Nvivo 7.0. The embedded quantitative data was analysed using SPSS version 13.0. Triangulation was achieved through the use of a meta matrix which merged the qualitative and quantitative data. The difference between integrated and non integrated services is expressed through the four themes, ‗the study participants‘, ‗commissioning and decommissioning integrated services‘, ‗the journey within day services‘, ‗navigating services and orchestrating care‘. The four themes were developed through a strategy used for interpreting the findings, which was to follow the study questions, propositions and ‗emic‘ questions. The differences between the integrated and non integrated services were in the meaning of their purpose, culture, level of integration, team orientation of practice and the model of service user/carer relationship observed within the services. The thesis identified challenges in respect of integrated working such as concept confusion, negative experiences of care for frail or older people, a vertical gap in knowledge transfer between strategic organisation, the operational services and service users. Mapping each service level of integration and team orientation to the model of service user and carer relationship, found that the level of team orientation and integration does not appear to be proportionate to the service user and carer relationship. The thesis concludes that in order to attempt to answer the question as to whether these day services can integrate in the practice, all levels of the system should focus on the service user/carer relationship. We need to understand service user diagnosis, how its characteristics and effect are interpreted by the service user, carer, professional and wider society in relation to independence and autonomy. It argues that knowledge emerges at this micro level (service user and carer relationship) and how we engage with this relationship and manage the knowledge we gain from it (both vertically and horizontally), will lead us to understand how we can ensure that integration occurs and that services in the future are person focussed. TABLE OF CONTENTS – VOLUME 1 ACKNOWLEDGEMENT II ABSTRACT III CHAPTER 1 INTRODUCTION 8 1.1 OPENING QUOTATIONS AND SERVICE USER VIGNETTE 8 1.2 BACKGROUND 9 1.2.1 Demography 9 1.2.2 The demography of a ‘welsh borough’ 12 1.2.3 Definitions of old age and frailty 13 1.2.3.1 Old age 13 1.2.3.2 Frailty 15 1.2.4 Devolution and its impact on service delivery in Wales 17 1.3 CHAPTER CONCLUSION 22 CHAPTER 2 INTEGRATED CARE FOR FRAIL OR OLDER PEOPLE: A REVIEW OF THE LITERATURE 26 2.1 INTRODUCTION 26 2.2 SECTION 1: DEFINING INTEGRATED CARE 29 2.2.1 What is integration? 29 2.2.2 Rules, laws and classifications of integration 31 2.2.3 Definitions of Integrated Care 33 2.2.3.1 Clinical integration 34 2.2.3.2 Professional Integration 36 2.2.3.3 Organisational integration 39 2.2.3.4 Functional integration 41 2.2.3.5 Systems integration 42 2.2.4 Vertical and Horizontal integration 43 2.2.5 Section Summary 44 2.3 SECTION 2: THEORIES OF INTEGRATION IN THE CONTEXT OF WORKING WITH FRAIL AND OLDER PEOPLE 46 1 2.3.1 What is a theory? 46 2.3.2 Theories which give meaning to integrated care 49 2.3.2.1 Systems theory 49 2.3.2.2 Complexity theory 53 2.3.3 Theories which show us how to integrate 58 2.3.3.1 Contingency theory 58 2.3.3.2 Collaborative theory 60 2.3.3.3 Configuration theory 61 2.3.3.4 Network theory 64 2.3.4 Theories that give meaning to the service user world 65 2.3.4.1 Successful ageing and autonomy 66 2.3.4.2 Human Need 69 2.3.5 Section Summary 71 2.4 SECTION 3 INTEGRATED CARE MODELS AND MECHANISMS 72 2.4.1 Law One 72 2.4.1.1 ‘Linkages’(Leutz, 1999; 2005) 74 2.4.1.2 Coordination 75 2.4.1.3 Full integration 79 2.4.2 Law 2 85 2.4.3 Law 3 87 2.4.4 Law 4 90 2.4.5 Law 5 92 2.4.6 Law 6 95 2.4.7 Section summary 97 2.5 CHAPTER CONCLUSION 97 CHAPTER 3- THE CONTEXT OF INTERMEDIATE CARE FOR DAY SERVICES: WHY USE HERMENEUTIC INTERPRETATIVE ANALYSIS AND A CASE STUDY? 100 3.1 INTRODUCTION 100 3.2 SECTION ONE: SETTING THE CONTEXT FOR DAY SERVICES: DEFINING INTERMEDIATE CARE 101 2 3.2.1 Introduction 101 3.2.2 The definitions 102 3.3 SECTIONTWO - HOW GADAMER’S HERMENEUTIC INTERPRETATIVE ANALYSIS WITH A CASE STUDY DESIGN EVOLVED 107 3.3.1 Introduction 107 3.3.2 The methodology 108 3.3.3 The Design 114 3.3.4 Using mixed methods within the case study design 122 3.4 CHAPTER CONCLUSION 127 CHAPTER 4 THE CASE STUDY DESIGN AND METHOD 129 4.1 INTRODUCTION 129 4.2 THE STUDY AIM
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