Ester Sarquella is a social pedagogue, educational psychologist and Master in Public Service Management. She works as a member of the Operational Committee of the Catalan Government Plan for the integrated health and social care. 

What do you think are the main pros and cons of a health and social integrated care model?
First of all, it is clear that any transformation made in the model used will not only bring positive changes but also some obstacles. From the users’ point of view, the advantages are clear: the integrated care model that we present – which is already being applied in other contexts – aims to fix divisions that have been artificially created in complex situations. The systems establishes a framework of care and defines what the health and social needs are. When facing complex situations the advantages of an integrated care system are evident. When situations are not really complex, fragmented care doesn’t have a big effect in quality and care, but as the level of complexity increases we find that more professionals are involved, more resources are used, situations are more likely to be unstable or unpredictable, and clinic, personal and social problems become a significant burden. For this reason, providing integrated care (planned, proactive, coordinated and continuous) offers clear benefits.

From the system’s point of view, we approach integrated care as a challenge to combine health and social systems. If we aim to improve the health and well-being outcomes of the general population, while guaranteeing an optimal use of resources, it must be done with an integrated approach. The fragmentation between health and social care is currently causing an inefficient use of resources. Integrated care is instead pursuing the optimal usage of resources to ensure the sustainability of the system, as well as to ensure the quality of care and a better experience for patients who are in complex situations.
As for the drawbacks, they could only be expressed through the voice of certain professionals or by analysing sector vs sector. For some of the actors who are part of the system, integration can lead to changes in different areas: status, the development of their professional role, their providers’ business model, the hiring mechanisms, the game rules… That can happen if you analyse it individually, but if we think about the rights and duties of the general population, an integrated care system does only offer advantages. Regarding the PIAISS, Catalonia is said to have a very suitable care model for the integration of this system.

Why? Which are the features that make it so suitable?
What the PIAISS is promoting is not starting from scratch. We have plenty of accumulated experience, both at the governmental and local levels. Despite the fact that the previous experience has failed to fully implement the system, it has been useful as an excellent starting point to reinvigorate the agenda. In comparison to other European states, Catalonia’s strength is reflected in the strength of primary care.
It is also true that regarding basic social services, such a decentralised organisation has given the system a certain subsidiary quality, resulting in a closer proximity to citizens. We can say that the previous experience combined with the robustness of primary care networks and community-based devices has been decisive.

It should be added that the intermediate care network in Catalonia is very good: intermediate stays, convalescence, recovery, end of life… All of this is extremely powerful in Catalonia.

Finally, another interesting element is the general consensus: professionals say that the best course of action is not the creation of a third space but the transformation of the two existing ones, in order to enable them to take care of patients in an integrated way. This way is much gentler to the identities and strengths of the two sectors.

What are the main obstacles in implementing an integrated care model?
The list is quite long. First, the obstacles have to be seen as “elements to take into account” in order to address them clearly and transform them into a strength. The Health and Communication Foundation is carrying out a study to predict which are the possible scenarios and learn what elements can facilitate or hinder this transformation. Pending the results of the study, I would say that regarding history, culture and construction, the two systems have progressed in parallel, not together: The roles of professionals, the care provided to people… All of that requires transformational processes beyond moving structures, contracts or systems that are in the collective imaginary of the systems.

On the other hand, there are elements that have more to do with the departments’ structure. Sometimes, when we talk to professionals, they tell us that they already know what to do regarding people’s care. The main problem that prevents intervention is related to the structure and organization of the system: rigid regulations, split portfolios, information systems that are unable to work together, evaluation mechanisms that discourage collaborations because they establish competition regimes or do not establish shared-vision … These instrumental elements articulated by the system only manage to hinder. Flexibility in the use of resources and certain devices would help guarantee high-quality care in an area. The pace of the systems, the entry or purchase requirements and the evaluation are so different that the system itself generates obstacles in this stage.

It should not be forgotten that a major obstacle is the precisely the strength of each system: we want two systems to operate in an integrated way when one of them has a budget of 8500 million euros and the other of 2500 million (between regional and local governments). That is why sometimes when the health system tries to interact with the social system it gets a frustrating answer, because the responsiveness is quite different. We must rebalance the right of accessing to social and health care.

Should we understand that the role of this two sectors remains back to back? Or are they becoming closer? What must be done for them to get closer?
There are many professionals who are working together to provide a better service to the population. The problem is how to make this good practice to become a standard and a warranty. We have excellent professionals in the two systems and if they had more tools to facilitate this collaborative practice the results of their work would increase exponentially. That part of the imaginary in the clinical and professional practice needs instruments or strategies to accompany this change of role for professionals. Different initiatives have been promoted, like Fòrum ITESSS, which is a private organisation that aims to encourage professionals from different disciplines to integrate their services.

We have to know each other but it is also important to recognize ourselves as valid interlocutors, to value the positive elements of different points of view and to offer shared and joint spaces…

Like the SomaPsy Summit.
Exactly. The integrated care model that we promote requires us to conceptualize and build a system with consensual strategies with professionals, based on a common model. Our work only makes sense if we do it from a territorial basis and, above all, if we identify professional leaders building the “how to”. An environment like the one provided by the Summit brings professionals from different areas together to think about common challenges, and that is very positive.

Are there any initiatives that you would highlight from the integration of social and health care services?
For us, the most decisive thing is what happens at the territory level. There was a time in PIAISS when the strategy was being designed and planned as it was being implemented. That allowed us to begin the implementation of this system in certain territories even if we didn’t have an answer to everything, but, on the other hand, this territorial implementation is helping us to make appropriate decisions when modelling. There are territories where plenty of things are happening. La Garrotxa or El Pla de l’Estany are two clears examples of places where the implementation is taking place, since they have been working with shared strategies for a few years. Alt Prineu, Alta Ribagorça or Alt Urgell are three territories that have begun to create working groups to see how the care model can be optimized. Other territories that continue with the implementation of the strategy are Osona, Alt Penedès-Garraf, Lleida, Reus… There are many areas involved.

On the other hand, in some areas we are focusing in very specific fields: in the City Council of Barcelona, they have just begun to work the integration strategy of information systems. For us it is very positive to have an agreement signed between the Health Department and the City Council, through which it was determined that the shared history of Catalonia and the information system of basic social services of the city council are interoperable… Each territory is helping us to conceptualize and make good decisions in the definition of the model. Furthermore, we have promoted initiatives for discussion and reflection, such as the Fòrum ITESSS, the advisory board, the participation board, or even the preparation of documents.

What would you say the reference models for the integration of health and social services are?
We are moving forward in parallel with other regions of Europe, and some aspects can be learned from international models (the same way they can learn from us). In terms of governance (implementing a top-down strategy, making laws, integrating budgets or making shared governances) we have the same vision as Scotland. However, they can learn a lot from our digital strategy, which is one of our greatest strengths. On the other hand, countries like the United Kingdom are promoting many pilot projects, cutting-edge integration projects based on the territory and self-discovery. Other examples of regions with integration models would be Southern Denmark, Northern Ireland, Flanders, the Veneto, a region of the county of Isère, etc. In Europe there are many regions that are wondering the same thing; they are using different strategies but they are looking to the same end.