Integrated care in practice: a case study of health and social care for adults considered to be at high risk of hospital admission

Integrated care is pursued globally as a strategy to manage health and social care resources more effectively. It offers the promise of meeting increasingly complex needs, particularly those of aging populations, in a person-centred, co-ordinated way that addresses fragmentation and improves quality. However, policy to integrate health and social care in England has led to programmes which have had disappointing effects on reducing hospital admissions and costs. My concern with the real-world problem of how to integrate care to reduce hospital admissions and improve quality whilst working as an NHS commissioner led to this study of integrated care in practice. The resulting thesis offers an interpretive account of the practice of integrated care across three Clinical Commissioning Groups. I present an ethnographic case study based on fieldwork undertaken 2014- 2016. My empirical work connected policy analysis with participant observation of 20 people with multiple, long term conditions considered to be at high risk of hospital admission and aspects of the organisational context. My main findings in relation to health policy and planning processes were that dominant discourses of integrated care (as a solution to a range of problems) are incorporated into institutional agendas and processes of power. NHS planning processes shape the context for a case of integrated care and prioritise the creation of bounded (but changing) planning units over historical and democratic configurations of places. I found that integrated care was not foregrounded in patientsâ experiences, rather it was a peripheral activity to their concerns to manage their daily routines, which required work to piece together networks of care and resources. I conceptualise integrated care as a lens through which the multiple emergent practices that comprise health care interactions with patients are viewed. Such a lens prioritises strategies to reduce hospital admissions, and marginalises aspects of integrated patient care. My analysis of this case makes an original contribution to understanding the tensions between policy aspirations for integrated care and the sometimes disappointing outcomes for patients by considering how integrated care programmes have little effect on external social structures, with a resulting reproduction of existing outcomes, such as hospital admissions, and continued separation of health and social care, rather than desired changes.