This edited volume had its origins in a workshop held in Austria during the autumn of 2000. The researchers had identified increasing policy and academic interest in the long-term care of elderly people and the need to integrate health-care and social-care services. Their European Union Fifth Framework R&D Programme funded project, PROCARE (Providing Integrated Health and Social Care for Older People), proved to be one of the key contributions to the discussions at a conference in Italy in October 2004 on the need for a new paradigm for long-term care. The volume under review distils the outcome of work undertaken by about 30 researchers from nine European Union (EU) countries. The case studies focused on two examples of pathways to integration in each of the nine member states. A central objective of PROCARE was to identify what the researchers called ‘model of ways of working’ to overcome obstacles to integrated health and social care. In addressing this objective, there was passing reference to broader issues of community care, covering other services such as housing, leisure and transport, but the notion of a ‘consolidated direct service model’ did not extend beyond the boundaries of health and social care, despite acknowledgement of EU policies on social inclusion, which focused on the notion of older people as active members of society. The first phase of the project addressed national overviews on ‘innovative practices of integrated care’ and was published in 2004 (Leichsenring and Alaszewski, Reference Leichsenring and Alaszewski2004).
The volume under review reports the results from the 18 case studies, which are characterised as the ‘most advanced “pioneers” of integrated care’, and identifies the ‘most prevalent issues and solutions in integrated care development’. Two introductory chapters overview attempts at integration and outline the methodological approach adopted to undertake the challenging work of cross-country case study empirical research. Data analysis was informed by an approach that permitted ‘the emergence and analysis of themes across the data’, labelled as ‘transversal themes’. These themes were explored in greater detail by cross-national teams of researchers which ‘helped to reduce interpretive difficulties and translation errors’ (p. 48).
The core chapters cover (i) the definition of integrated care from the stakeholder perspective (with modest reference to service users and carers); (ii) access to integrated care; (iii) inter-professional and inter-organisational working; (iv) key innovations; (v) the role of the family; (vi) staff views on working conditions in integrated care; and (vii) the outcomes and benefits of integrated care from the viewpoint of service users and carers. The core thematic chapters echo long-established concerns. What do different interests mean by integrated care? Is it professional, organisational or functional integration? How easy or difficult is it to access integrated care, whether by self-referral or as a result of the actions of professionals? How easy is it to make access procedures both comprehensive and manageable? The text appears to differentiate between a client-centred perspective, where information ‘should cover all care needs in the life domains of the person’ (including housing), and a narrower perspective of ‘organisational interfaces, where information should be shared with the relevant health and social care providers’ (p. 87). The issue of what should be included in integrated care once again appears to be unresolved, and the comment is made that ‘interviews with service users do not teach much about involvement in the assessment process from the clients’ perspective’ (p. 88). Although advocacy is mentioned, there seem to be no illustrations of such a service in the detailed case study descriptions.
On the problems of inter-professional working, the researchers conclude that integrated care becomes more feasible in an intra-agency rather than inter-agency setting, and that regular meetings, shared information, shared accommodation, supportive management and joint training facilitated the development of inter-professional working. Difficulties arise as a result of scarce resources, lack of career-development opportunities and professional defensiveness. The following chapter on key innovations illustrates extensively the set of characteristics that facilitate integrated care, such as individual care plans, multi-dimensional tools for needs assessment, monitoring arrangements and good information sharing systems. Yet again, user-centred care is less prominent than a professionally dominant care process: ‘It is much more difficult to show evidence for developments towards user-centredness as these are much more value-laden, “soft” and less concrete’ (p. 163). The next chapter focuses on informal carers, mainly family members. The evidence from the case studies reinforces the familiar profile of major changes in household structures, the ageing of the population and the transformed role of women in the labour market. In addition, the recognition that carers need support from the state or other agencies is highlighted, such that the role of the family is no longer taken for granted. However, the central role of the family as primary informal carers is confirmed, and the circumstances of needy individuals who have no family are overlooked. This perhaps reflects the criteria used to identify the case studies. Reflections on the role of informal carers conclude with recommendations for national policy and local services, but do not comment on the level of resources required to implement the range of best practices identified, or the more effective use of existing resources to achieve the same aim.
The issue of resources is one of the negative features identified in the chapter on working conditions of staff in long-term care settings, together with lack of time to perform tasks adequately, a lack of supportive infrastructure and too much administration. On the other hand, many of the staff working in the case studies reported that they enjoyed their work, as it gave them a fair level of autonomy and the chance of seeing positive outcomes of their engagement with older people and their carers. This was particularly associated with what was called ‘the still developing professional profile’ (p. 223) of the care- or case-manager, a key player in an integrated care strategy.
The chapter on service users' and carers' views on the benefits of integrated care gave this reader something of a jolt. Compared with the detailed descriptions in other empirical chapters, this theme is not one of the original purposes of the PROCARE project: ‘This perspective became relevant during the project’ (p. 194). One of the consequences is an explicit reference to a social constructivist approach to the raw material of the project, emphasising the importance of the life or ‘real world’ approach rather than the systems approach focusing on service planners and providers. Second, it is the only core chapter of the book in which the concluding section is followed by a plea for much more ‘versatile’ research. Third, it may be relevant that the two authors of this chapter (Haverinen and Tabibian) were not listed among the authors of any of the detailed empirical chapters. The views of users and carers are scrutinised under the headings of integration, empowerment and social inclusion. On integration, the issue is raised about the relevance to users of professionally detailed integrated care. Great importance is attached to processes such as a single point of access, continuity of care (and carer) and to being involved on decisions on the provision of care. Negative comments reflect evidence of a lack of seamless care. Empowerment, it is suggested, is associated with a focus on the role of the aware, self-confident, critical consumer rather than on frail, very old people who may not be well informed, or indeed curious about, the range of possible providers of services. The authors remain unsure whether empowerment ‘is a concept understood, accepted and internalised by older users, or one that is socially constructed by professionals and policy-makers’ (p. 202). The commentary on social inclusion also emphasises the importance of continuity of care and familiarity of surroundings, not least in respect of elderly people described as lonely or socially isolated, but little attention is paid to the need for effective procedures for implementing the policy aim of social inclusion. Yet again, the aims are explicit, but achieving them in terms of resources required (or reorganised) is not addressed. This was reflected in the final chapter, which simply summarises the earlier chapters, identifying ‘elements for successful integration processes’ (p. 245) but noting that most of the case studies depended on vulnerable funding sources. The volume concludes with a plea for the intensification of inter-disciplinary research in care for older people. Perhaps the United Kingdom Research Councils' New Dynamics of Ageing programme is one response to this plea.
