My favourite character in JK Rowling’s Harry Potter books is Fluffy, the three headed dog. Now Fluffy might not have a lot to say and Fluffy’s part is small. But Fluffy stands in the way of Harry, Hermione and Ron in their quest. The only way to get past Fluffy is to play him music. Music will send Fluffy to sleep.

At this point you might start to wonder what Harry Potter, Fluffy and music have to do with social care and health integration, and I’d say what draws them together is that

• Fluffy stands in the way of our teams’ goal
• Fluffy is a many headed creature – thus creating a deep conundrum on how to get past Fluffy
• The best way the way to meet the fluffy challenge is teamwork (and music).

You might still think this analogy is slightly off beat. But let’s look at it a bit closer

• Process stands in the way of our integration goal
• Integration is a many headed creature – which creates a deep conundrum on how to make it happen
• The best way to meet the integration challenge is teamwork (and music).

When integration is working well, who the employer is, reporting mechanisms, who holds the budget and who makes decisions about different elements of what happens are irrelevant. That’s because people have learnt to trust each other, to be clear about what their common goals are and where it is okay not to have common goals.

It’s easy to hide behind the process of integration. To suggest that we can’t be integrated in our decision making until we have sorted out our formal structures for integration. That informal integration leads to ineffective decision making. But is this more of an issue of power? If there aren’t process driven models of integration, will certain people find that their influence and power over the health and care system is diminished? Thus becoming just another team player – rather than the conductor of the team.

Spending too much time on process is a great way to undermine effective integrated working. Time spent sorting out who is employed by who, at what rate and who can make ‘big decisions’ hinders integrated working to the detriment of people with support and treatment needs.

There is no denying that integration is many headed. What constitutes meaningful integration depends on how you and your team relate to each in order to meet team and individual objectives. It may be that if you work in youth services integrated working with education and the voluntary sector is more important than integration with health. If you work in adult social care supporting people with a learning disability integrated working with employment services might be your most important link. If you work the ambulance service integrated working with the police might be your key goal. If you work in an acute hospital, integration with other teams in the hospital is likely to be more important than working with social care.

As a many headed creature, context and purpose have to drive the reasoning behind any move towards integrated working. When the context and purpose for integration is focused around a shared objective, such as improving outcomes for expectant mothers having their first child, or enabling people with complex health needs to live at home as independently as possible, the outcomes from any model of integrated working are much more likely to be positive.

Teamwork is the key to meeting the integration challenge, and teams that can be integrated in their behaviour regardless of their formal structure are likely to be better placed to flexibly deliver new and innovative approaches to how people are supported with their care and treatment needs. A shared purpose around people seems more important than who you are employed by. Integration is about relationships, trust and breaking down barriers, with less of a focus on organisation, process and role. The whole being greater than the sum of its parts by working together effectively. Moving away from doing to, and getting people involved in being  part of the solution are essential to how good integration works.

Integrated working solutions value the importance of working together, over all being employed together. It is much easier to challenge each other when we know that we are responding to different hierarchies. We feel safer to disagree when our ultimate arbitrators are different. Person centred support and treatment built by people with leaders who are focussed on the whole population, not specifically focussed on their own organisation, business or professional role.

So why is Fluffy so relevant to integration? At its best integrated working is very ‘fluffy like.’ It has its biggest impact when people get together to solve problems together, without being completely clear what the problem is, how they solved it, and with a level of surprise at the impact they have on peoples care, support and treatment. If we think that a structured process approach to integration is going to solve all of the working together issues that people in health and social care face, we miss the point completely.  Maybe more time spent learning to play music together, understanding the value different voices bring to the whole, being able to adapt as different voices change the ambiance, helping the soloists to feel less in charge and helping the shy voices find their pitch and perfect note could help all of us benefit from integration. Less following the written music and more improvisation so that we can all find our voice. More fluffy less fluff.

References

Harry Potter and the Philosophers Stone (1997) JK Rowling, Bloomsbury Press

Jim Thomas

Jim Thomas is Head of Workforce Innovation, Recruitment and Retention at Skills for Care, the workforce development lead organisation for adult social care in England. Jim has been engaged in social care and health for 30 years. His work has included leading national programmes on workforce redesign, the development of principles for workforce integration, skills led approaches to community development,  safeguarding, workforce commissioning, commissioning qualifications, personalisation, exploring workforce wellbeing, workforce productivity and workforce outcome measurement, developing the workforce supporting people with a learning disability and autistic people, exploring workforce issues on digital working, learning, information sharing AI and robotics.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: Skills for Care employee for last 14 years.