Patient comment: Hospitalisation among patients with diabetes associated with a Diabetes Integrated Care Initiative: a mixed methods case study
OVERVIEW
Patient comment on ‘Hospitalisation among patients with diabetes associated with a Diabetes Integrated Care Initiative: a mixed methods case study’ by David Simmons, Dahai Yu, Christopher Bunn, Simon Cohn, Helmut Wenzel and Toby Prevost
Ask patients with long term conditions what they find most frustrating about the UK healthcare system and they will invariably comment on the fragmentation of care, characterised by poor communications between agencies, and the absence of a coordinated and personalised care package. They often experience difficulty navigating the system, which can lead to suboptimal care and a feeling that clinical outcomes might have been better if services had been properly joined up. Patients with diabetes are usually sharing decisions about their care with clinicians and need support for self management across the whole healthcare spectrum. They rightly expect ease of access to primary care, specialist community-based services, diagnostic services and, when complications in their condition arise, to secondary care. Patients also prefer to receive their care in local settings close to home, if not in the home. Usually they take the view that the less time they spend in hospital the better.
The Diabetes Integrated Care Initiative (DICI) in East Cambridgeshire and Fenland set out to develop a new model of integrated care aimed at improving clinical outcomes and increasing patient access to specialist care. The conclusion that the DICI did not lead to improved care or less reliance on inpatient care is disappointing but clearly some patients viewed the enhanced community services as a step in the right direction. The extent to which patients were involved in the design of the DICI is not clear. Early involvement of patients in service design and in agreeing success criteria might lead to better outcomes. While patients want good community-based care, they also want speedy access to secondary care when they develop complications. Delays in referral from primary and community intermediate care to secondary care are a common complaint among patients and there may be a benefit in some situations to allowing a degree of self-referral to hospital specialists by those with complex long-term conditions. Also, patients see the sharing of information between different components of the service as being of vital importance and it is unfortunate that electronic data sharing was not allowed between general practice and other health services. Despite the lack of information sharing systems, many patients felt the DICI was delivering more personalised care.
While the DICI was associated with worsening hospitalisation rates, it did report many positive patient experiences. What is important to the patient is not always seen as important by the doctor or manager. Quality-of-life issues are often as important to patients as are clinical outcomes. Maybe there is a trade-off between convenience and outcome. We should not underestimate the importance of patients receiving the best evidence-based treatments at the right time, but likewise we should not underestimate the desire of patients to see care tailored to their individual needs and personal values. Patients like to be given options for their care and treatment and the DICI clearly introduces a new service component that is more accessible than the hospital-based service. Patients want truly joined up care, ease of access to all parts of the system and, most importantly, a named professional who can help steer them through a complex health system. Patients should be integral to the development of new models of care and the success criteria for new ways of delivering care should include the quality of life issues which are so important to patients.
The Future Hospital Programme development sites are currently engaged in the design of new models of care, guided by the recommendations of the Future Hospital Commission. They will explore ways of delivering seamless and timely care to patients. The experiences of patients who have used the DICI are relevant to the work of the Future Hospital Programme development sites and it is to be hoped that lessons will be passed on. Similarly, recent government announcements that the drive towards delivering integrated care is to be accelerated, will provide opportunities across the country to look at new ways of working by breaking down the barriers that exist between hospitals, GPs and community services. It is vital that those planning these new ways of working reflect on the achievements and the disappointments reported through evaluation of projects like the DICI.
The DICI has clearly been a success for many patients and has, despite its failure to prevent some hospital admissions, added a new component to the range of services previously available. There are some important lessons to be learned for those charged with developing integrated care and a plea from patients would be for commissioners and providers to work with them and with carers to ensure the opportunities for new ways of working address what is important to them from the perspective of integration, quality of life and clinical outcomes. Patients and carers would also like to see politicians promote policies which encourage integrated care and collaboration between providers rather than the fragmentation of services which can be one of the consequences of pursuing market principles.
- © Royal College of Physicians 2015. All rights reserved.
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