Thesis Content

A flow chart of my thesis, setting out my research questions, approach, key findings and conclusions is shown in Figure 1. The table provides a way of navigation, and provides a guide to content in each chapter.

In Chapter 2, I have carried out a literature review on the disciplines of research and consultancy and examined the differences and similarities. This introduction has highlighted the need for the author to change roles from consultant and advocate to researcher. As this is fundamental to the legitimacy of this research, I have addressed the challenges of using data from consultancy for research, set out how the integrity of the research will be maintained, and explicitly addressed the limitations of this approach. This has helped to frame the research approach and understand how to interrogate and manage the data sourced from consultancy and interpret the findings.

In Chapter 3, I have reviewed the literature on integrated care, considered where integrated care is taking place, and how it is being developed. There were a number of questions I wanted to explore, such as why we are interested in integrated care at this time and when did it become an important factor in health and social care. I wanted to know more about what integrated care meant in different health care systems and what the experience internationally was of designing and developing integrated care systems.

40 I hoped that the review of the literature would further clarify the definition of integrated care and provide evidence of how integrated care is being designed, developed, and sustained in community health services. My experience in community health services had led to me to believe that integrated care was taking place more widely than had been recognised, both in supported structured programmes and also in an informal way of working, and I wanted to explore this further. In particular, I wanted to explore the literature on processes and systems that supported integrated working such as those concerned with care management and information systems, and explore this further in the integrated care programme case study in Ireland. From the review of the literature I developed a conceptual framework of inclusivity, whereby I challenged the

predominance of an exclusive service of integrated care focused on model short term projects with one type of integration and designed for one client group, namely older people.

I have devoted Chapter 4 to community hospitals and their history, role and function in order to determine whether there is evidence of a tradition of joint working in local hospitals, how this manifests, and what pertinent factors influence the extent of

networking within and beyond these hospital services. I have explored the partnerships in community hospitals and, from the literature, identified eight frequently occurring types of integration. These were integration between community hospitals and: primary care; secondary care; social services; Local Authority; the third sector; patients and the community as well as integration between professionals.

41 The rationale for my research approach is presented in Chapter 5, with an appraisal of methods for my research approach. This includes an assessment of the extent and limitations to the study, particularly in regard of the secondary analysis of qualitative and quantitative data that had been collected for evaluation purposes in the two case studies. Questionnaires completed by staff working in community hospital and

community health services provide the majority of the data, which I have analysed using themed content analysis. The findings on staff views and experiences on integrated care in community hospital services in England are presented in chapter 6, in which the frequency of occurrence of eight types of integration from the literature review are identified in 48 services. In addition, staff views of factors influencing service development are analysed.

The findings from the data analysis on staff views of the meaning of integrated care, the development of integrated working and the implementation of processes to support integrated working in community health services in Ireland are presented in Chapter 7. The results are contextualised within five services which are presented as embedded case studies.

The findings are discussed in Chapter 8 in the context of the concept of integration being inclusive rather than exclusive, and an approach to managing change in health and social care is explored so that integrated working may be sustained. In Chapter 9, I identify new learning, review the appropriateness and limitations of the research

methods adopted and consider the implications of the study. I consider the new learning about the presence of integrated care in local community services, its multi-faceted

42 nature in terms of types and components, and what can be learnt about the development, implementation and sustainability of integrated working. Following my overall

conclusions, I discuss the impact and implications of the study and identify areas for further research. I suggest the creation of a new framework for integrated care which sets out the features and principles of integrated care which may be generally applicable. This study contributes to the ongoing debate about the nature of integrated care and how integrated working is to be developed for the benefit of users of services. Figure 1 is a flow chart, setting out in diagrammatic form the content of my thesis by chapter.

43

The Presence, Nature and Development of Integrated Care in Community Health Services.

Two case studies: Community Hospitals in England (CHA I&BP) and Community Health Services in Ireland (ICON). Staff views and reported experience of integrating care – secondary qualitative analysis of questionnaires

Is IC exclusive?

Research Questions Chapter 1 Presence - Where is IC taking place?

Nature - What are the characteristics of IC?

Development – How is IC being developed? Literature Review CH Chapter 4

What is a CH?

What is the history of CHs? How have CHs developed? What is the role and function of a CH?

What is the international experience of CH hospitals?

Is integration evident in CH?

Literature Review Chapter 2 Management Consultancy and Research

How are management consultancy and research defined?

What are their similarities and differences? How may the understanding of the two disciplines help inform the design of this research study?

Literature Review IC Chapter 3

What is IC?

What is the social theory for IC? What is the health theory for IC? What are the characteristics of IC? What is the rationale for IC? Why is IC a global priority? How is IC developed?

How is development of IC managed? What is the impact of IC?

Analytical Framework Chapter 5

What are the types of IC?

What are the component parts (processes) of IC?

Conceptual Framework

Where is IC on Inclusive /Exclusive spectrum?

Analysis I&BP Chapter 6

48 service – community hospitals 8 pre-defined types of IC Factors supporting or hindering IC

Methodology Chapter 5

147 staff questionnaires for 66 services Case Study Approach

Secondary qualitative analysis of primary data Themed content analysis & triangulation

Analysis ICON Chapter 7

63 staff define IC

18 community health services 8 pre-defined processes for IC Factors supporting or hindering IC

Findings I&BP Chapter 8

Multiple types in all CH services 4 (median) range 2-8

IC for all ages and all services studied

Most types: palliative care, long term conditions and health promotion Helps: commitment,

Hinders: staffing levels and funding

Findings ICON Chapter 8

Multiple processes in all services 4 (median) at start rising to 5 at end IC for all ages and all services studied Most progress: children’s services, Most processes: disability services and primary care.

Small teams made most progress

Conclusions & Reflections Chapter 9 Presence

IC present in all services in this study

Nature

Multiple simultaneous types Multiple processes to support IC IC for all ages and services in this study

Development

Systems approach may be applicable

IC defined

Propose a framework of 5 principles

Inclusive/Exclusive

Research shows IC positioning on spectrum shows may be more inclusive.

44