Teams without Walls

Change has been such an integral part of the NHS for so long that identifying elements that have remained unaffected over time is rare. One such event might be the early separation of medical training for general practice and hospital medicine. This has led to two rather separate groups of doctors being responsible for the same patients. In the current era of ‘patient-centred’ care there has been much debate about how care might be improved if these two strands were better integrated. The government's intention is to provide care closer to home and, wherever possible, outside hospital. From the patient's perspective this is an attractive option but it must of course be safe, of high quality and cost effective when compared to current treatment models.

Some excellent examples of this practice already exist. Early intervention services have been introduced for the treatment of first episodes of acute psychosis in young adults where treatment and support is provided either at home or in the community. The outcome for patients in terms of remission and return to work or training are better than those achieved by traditional inpatient treatment. The increased costs of personalised expert care outside the hospital setting are more than offset by the reduction in costs by the minimal use of inpatient care. The ‘customer satisfaction rating’ is also high.

How far this model is capable of generalisation has been the subject of much debate. In this issue Rodney Burnham and Jonathan Steel summarise the outcome of a King's Fund conference on this topic held in June 2008 (pp 74–5). This was a joint venture between the Royal Colleges of Physicians, General Practitioners, and Paediatrics and Child Health. At its heart the conference discussed a major initiative from all three colleges, the report of a Working Party, endorsed by the NHS Alliance, entitled Teams without Walls.¹ The report explores integrated models of care which cross the traditional primary and secondary care boundaries but which also include high-quality, safe and cost-effective care as an essential prerequisite. Many examples of interface working are quoted where practical implementation has proved effective. Much has been achieved and much remains to be done but the direction of travel is set. It will become clearer with time what can and what cannot be changed in the delivery of care closer to home.

• © 2009 Royal College of Physicians