What is integrated care?
Integrated care means care which is organised around the needs of individual patients. . Integrated care is not about structures, organisations or pathways – it is about better outcomes for service users.
There is now a clear consensus that successful integrated care is primarily about patient experience, although all dimensions of quality and cost-effectiveness are relevant
Further, integrated care is clearly not an end in itself, but is an essential tool to improve outcomes for individuals and communities.
In order to show why a smooth journey through the NHS is desirable, it is important to understand what a non-integrated system looks like and the experience that service users face when navigating through a fragmented system. For e.g. a diabetic patient may need services of the following: cardiology team, GP, practice nurse, renal team, diabetic team, diabetes specialist nurse, GP, practice nurse, vascular team, foot team, eye team, retinal screening team etc. This illustrates the complexity service users must navigate and, therefore, highlight the need of a more integrated system.
What are the problems with the current non- integrated care system?
- Lack of ‘ownership’ for the patient and her problems, so that information gets lost as she navigates the system
- Lack of involvement by the user/patient in the management and strategy of care
- Poor communication with the user/patient as well as between health and social care providers
- Treating service users for one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment
- Lack of integration between health and social care- although decisions made in the social care setting affect the impact of health care treatment, and vice versa.
Is integrated care really needed?
The NHS is faced with the major challenges of using resources more efficiently and of meeting the needs of an ageing population in which chronic medical conditions are increasingly prevalent. The key task therefore is to implement a new model of care in which clinicians work together more closely to meet the needs of patients and to co-ordinate services and enable people with complex needs to live healthy, fulfilling, independent lives.
This model of integrated care would focus much more on preventing ill health, supporting self-care, enhancing primary care, providing care in people’s homes and the community, and increasing co-ordination between primary care teams and specialists and between health and social care
Integrated care is the only way to make health system sustainable in the long term by transferring care out of expensive hospitals and nursing homes in the community or even in patients own home.
What are the aims of integrated care?
- Improved patient experience- by providing a seamless service reducing gaps and duplication in service
- Improved patient outcomes i.e. improved quality
- Improved cost effectiveness of care by improving system efficiency
- Better experience for medical staff
However it is important to point out that more integrated care is not always the right answer to improving the patient’s experience and system efficiency. Integrated care also carries some risks, such as that of reducing competition, and incentives to improve quality.
How would you develop integrated care?
- There are no general rules
- Benefits depend on the specific design and approach to integrated care based on local circumstances
- Learn from successful examples
- Take patients view into account
Successful integration depend on which approach is used, how well it is implemented, and on features of the environment in which a provider is operating, including the financing system.
What are the barriers to integration?
- Organisational boundaries- Primary or community care and secondary care or hospital care, social care (provided by LA) and health care- making it difficult for services to be properly coordinated. This leads to gaps and duplication of services. In a fully integrated system, patients’ needs not organisational boundaries would decide how care is provided
- Lack of shared record keeping about a patient (GPs, hospital, nurses, social care workers)- hence patient and carers end up telling the same story to healthcare professionals. Lack of this info also cause poor care for e.g. a patient may turn up in ED and lack of info would not help
There are other barriers like:
- Payment by Results provides hospitals with some incentives to keep patients in hospital rather than treating them in the community.
- Service users choosing alternative providers: service users have freedom of choice regarding their elected place of care. However, this freedom can create deviations from the planned pathway of care and may cut across attempts to provide integrated care.
How can organisations enable integrated care?
Several measures could potentially mitigate these barriers. They may include:
- Personal budgets
- Make it easier for service users and carers to coordinate and navigate. This implies that every service user with long‐term or complex needs has easy access to a “care coordinator”, or federations of GP practices who can act as the coordinating point for all of their care.
- Information is a key enabler of integrated care. Care records should be electronic and accessible at the point of care throughout the whole care journey, regardless of sector or provider
Can we do it?
NHS has spent the last decade or more in ensuring faster and easier access to GPs and consultants; reducing waiting times etc. and indeed vast progress has been made in these areas.
This was made to matter to the managers and clinical leaders- we need the same focus- the same urgency and importance being attached to patients with long term conditions, frail older people- and only when it matters that integrated care will become a reality.
What can we do to facilitate integrated care?
- Clear policy directive as to why integrated care is important- we spend too much in acute hospitals, care to individual patient is poor and if we don’t change the system- it will never become a sustainable system
- Sustained support for people seeking to develop integrated care locally- support in the form of using data analysing population need, project management,
- Evaluation of integrated care initiatives- so that we can learn
To me it means that things are joined up, not fragmented into different parts with no one person informing all the relevant agencies about your needs and condition. Importantly also integrated care must include the persons wishes and needs, too often at the moment the person is left out of the loop! In my experience I am ‘told’ what I can and can’t have regardless of my needs and wishes. This is the same for many unfortunately.