The government has used the Spending Round to create a £3.8 billion pot to be invested in local pooled budgets to drive integration of health and social care services. It heralds a real opportunity to redesign services around the needs of the service user, and in so doing, provide a higher quality of care and take some pressure off NHS acute services.
It will be for local areas, led by the health and wellbeing boards, to decide what whole system integration should look like for their areas. We can’t prescribe that from Whitehall. But we do have enough examples of successful integration, both here and abroad, to be able to map out some of the central characteristics. Further details of how we will be putting the Spending Round’s requirements into practice will follow soon, but for now, in no particular order, here is my quick-fire top 10.
- The importance of clinical leadership in driving integration: This is not to diminish the importance of local political leadership, but if we want to see sustainable changes to care pathways to improve patient experience and reduce costs, then the evidence from those who have been successful is that you need a critical mass of clinical leaders from the primary, community and acute sectors. I have seen this in a number of places recently. In Dudley, I was very impressed with how the clinical commissioning group (CCG) clinical leadership were using data to drive improvements in primary care. In Cornwall, that leadership had been employed in combination with social care leadership to create an improved pathway for frail elderly taken into hospital that extended into an intensive reablement service on discharge. Drawing on my recent visit to the US with the Minister of State, at Intermountain in Utah they ensure that both primary care and acute physicians are working together on different aspects of service redesign.
- Developing an integrated care offer within the community: This is what the Americans would call the ‘medical home’. It means developing a seamless relationship in care co-ordination between GPs, community health and social care. There are a number of ways to achieve the same end, and what works in an urban area may not work in a more rural context. One international example is the work in Maastricht in the Netherlands where they have developed an integrated community model for treatment of diabetes. A UK example would be Tower Hamlets’ approach to care of people with dementia. What we are now seeing are UK examples demonstrating this degree of integration for people with multiple long term conditions.
- The importance of strong preventative services at neighbourhood level: Often led by the third sector, these services can provide a thick layer of community resilience, helping to take the pressure off all parts of the health and care sector. Better still is where these community services are treated as an integral part of the community health and care team. In Newquay, the professionals and the voluntary sector work proactively with an identified cohort of frail elderly citizens, who are vulnerable to crisis episodes requiring hospital admission. By working interchangeably according to service user needs they have achieved a 23% reduction in non-elective admissions for the group. In Leeds, the comprehensive system of 27 neighbourhood networks, led by a blend of voluntary organisations and social enterprises, work with the integrated professional community teams – GPs, nurses, social workers, therapists – to deal with a spectrum of need from loneliness and isolation through to intensive support on discharge.
- A commitment to data sharing: This integrated community offer mentioned in my third point has to be based on effective risk stratification, underpinned by a commitment to data sharing. For example, in Kent they use predictive models to identify the cohort most in need of preventative social care support. They then use what they call ‘anticipatory care plans’ developed with the individual and their support network to plan their health and care needs, including what they can contribute themselves to meeting those needs, thus slowing down the requirement for more intensive support.
- The intensity of care co-ordination within acute settings: Whilst visiting a Kaiser facility in the US, I was struck with how this process started from the point at which the individual arrived at accident and emergency (A&E). The collective mindset from the outset was about the individual’s pathway to successful discharge back into a community setting. This also means ongoing communication between the lead hospital consultant and the primary care physician, particularly during longer stays. I also know that in a number of places in the UK, social workers now play an important role in A&E, supporting triage and providing alternatives to admission.
- The importance of taking an integrated approach to mental and physical health: This should mean ease of access for GPs to psychotherapeutic services, a renowned feature of North American integrated care organisations such as Beacon and the Veterans’ Association. It also means having ready access to mental health support within A&E, as exemplified by the RAID model used successfully in Birmingham.
- The adoption of a scientific approach to achieve improvements in the quality of the care experience and care outcomes: This might mean adopting a quality system borrowed from another sector such as Six Sigma or the Toyota lean model, or it may mean creating something more bespoke. The underlying principle is that integration leading to improved outcomes is rarely if ever achieved by one big structural leap, but rather a myriad of detailed changes to care pathways, operating procedures and care environments, led by professionals following the evidence. I visited one organisation where by adopting such an approach they had dramatically reduced hospital deaths through sepsis.
- The commitment to use of digital technology to support the integrated system: This means moving to single electronic care records and a comprehensive system for secure data transfer.
- The whole system supporting self-management of care to the fullest extent possible: This is a link to my previous point. This means enabling the individual to access and use their own health and care information , a strong use of assistive technology and an openness to electronic exchange of information between service user and their care team, including the GP.
- Great integration doesn’t end with health and social care: It draws in other services where they can make a contribution, such as housing providers to ensure well designed living environments, or transport providers to enable enhanced access to community services, to name just 2.
This is, of course, by no means the full story. I have said nothing for example about out-of-hours services or the role of pharmacies. Nor have I talked about the need to achieve integration on both the commissioning and provider sides, and the choices that entails. I also haven’t said anything about aligning incentives across the system. Perhaps there is a case for another blog, or perhaps I should just wait to see what the pioneer bids bring forward. The deadline was last Friday for the bids and in September we hope to announce the ten or so localities that will move quickly forward in partnership with us to establish whole system integration. When combined with the Spending Round announcement and existing activity in different parts of the country, there is a strong sense of momentum and a feeling that this time we can make integration a reality for the benefit of service users and their carers.
