Integrated care policy implementation in England: A case study of a community based integrated care service

Discussion relating to the boundary between health and social care has existed since the inception of the NHS, with successive governments proclaiming the desire to ‘integrate’ care. This thesis draws on data collected from a case study community based integrated care service (CBIC), to explore the relationship between the macro level political environment governing health and social care integration in England, and the micro level managerial and organisational practice shaped and enacted within this context. Data collection took place between April 2017 and April 2019, using textual analysis, qualitative interviews and participant and non-participant observation. The methodological approach developed in this thesis integrates Fairclough’s Dialectical Relational Approach to Critical Discourse Analysis and Realist Evaluation, as a means to connect integrated care policy discourse with its enactment and operationalisation at the level of practice, within a critical realist ontological and epistemological position. Previous research has argued that integrated care policy works as a discourse to manage tensions between competing policy aims and to allow the continuation of austerity and fragmented health and social care services. Moving beyond its linguistic realisation within government policy texts, this thesis demonstrates how this discourse was put to work through implementation by actively shaping the materiality, managerial practices, and subjectivity of actors to mobilise neo-liberal economic austerity. Specifically, the resource pressure within the CBIC had a socially structuring effect on how the managerial, organisational, and technological resources sought to shape the subject positions of both health professionals and patients through the lens of ‘waste watching’, when attempting to implement integrated care. This had a dislodging effect on concerns for improvements in patient experience and resulted in work intensification, stress, and lost application of skill for staff.