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Patients falling between 'gaps' in care has been a problem faced by health and social care professionals for years.

Anyone who has used, delivered or observed the transition an individual makes between the two services during the journey from hospital back into the community can vouch for that. And we've all heard the stories of where it’s not worked out quite as well as it could have done.

Examples abound of individuals slipping through ‘gaps’, missing out on the care that would help them get better more quickly, or of elderly patients exasperated at having to re-tell the same story to different health and social care staff.

At times even the notes go AWOL, people are discharged to an inappropriate unit, or the visits from health or care workers are at different times and don’t exactly tally with people’s daily requirements.

We know that without good communication, strong working relationships and a few astute questions from the patient or service user, there’s potential for it all to go awry.

That’s why the government is endeavouring to bridge the gap by bringing health and social care together. It’s to provide a seamless service where cohesive social and health care teams made up of professions such as nurses, social workers, occupational therapists and physiotherapists work more closely.

The challenge, however, lies in integrating the two sectors as effectively as possible for the benefit of the 2018.

The importance of placing the person at the centre of care is widely acknowledged and the plan to integrate health and social care genuinely aims to achieve that by providing care that is coordinated and tailored to the needs and preferences of the individual, and of carers and family members too. It’s a more holistic approach to health, care and support needs.

The government says co-ordination will see better care and support, fewer people falling through the cracks and a drop in patients needlessly stuck in hospitals. Or as NICE puts it, “better integration of health and social care services is a critical part of delivering efficient user-centred care.”

The Care Act, which underpins all of this, has opportunities for social work and those entering the profession to help shape a new era in care delivery. There will be challenges, but rest assured positive results have been achieved through services already delivering integrated care – for all those involved. 

Social work has a track record of working across interdisciplinary boundaries and putting people’s needs at the core of decision-making, however, under the new protocols, the social care workforce will have to adapt and work more collaboratively with health care, housing and other sectors.

Potentially, the biggest challenge will come through working as part of an integrated team with healthcare and other professionals and acknowledging there will be a single governance structure and budget behind it all. Working environments will experience changes too, with different cultures and performance and outcome frameworks. 

Concerns over trying to remember which parts of the old legislation will remain in place alongside the new act have been raised by social workers, along with deciphering the boundaries of responsibilities. 

Such issues were raised under the consultation process for the Care Act. Healthcare professionals have had their say too, not least the fear that giving control to councils may lead to a blurring of the lines between NHS and local authority responsibilities and, pointedly, of their respective budgets. Reassuringly, much of this has been clarified by the Government in their consultation feedback, confirming that the Care Act does not seek to alter the boundary of responsibilities of local authorities and the NHS. 

On money matters, the government has set £3.8bn aside in the so-called Better Care Fund (BCF), which is a single pooled budget to support health and social care services work more closely together in local areas. However, it doesn't address the financial pressures faced by local authorities and CCGs and there may be local interpretations on priorities and targets.

An important element is the 14 pioneer sites - spread across England from Cornwall and the Isles of Scilly to Leeds and South Tyneside - which have been established as exemplars of good practice in delivering integrated care and support locally. They show, that with the right approach, it can be done…and can work well.

In Greenwich, for example, it has been suggested that over 2000 patient admissions were avoided due to the work carried out by a team made up of nurses, social workers, occupational therapists and physiotherapists.

Meanwhile, in South Devon and Torbay, getting in touch with a social worker, district nurse, physiotherapist and occupational therapist now requires just one phone call, rather than several.

The message, and aim, is clear: that by working together, staff from all sides can more easily identify the patients most at risk and then act promptly to put together a combined package of care, support and lifestyle advice.

That is a package that will keep people healthier, potentially happier, and maintain their well-being and independence for longer.

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