Integrated care: the clinicians’ view
Introduction
Moving the NHS towards an integrated care service is a key priority according to a number of recently released strategies, plans and policy documents.1–4 Indeed, the 2014 NHS Five-Year Forward View (5 yr FV) is built on a consensus among patient and front-line staff that this is how care must be provided in the future.5 Central to this is the expectation that services for long-term medical conditions can and must be delivered outside the hospital setting.6 While this may at first appear to threaten hospital consultants, in reality it provides an opportunity for all medical specialties to help shape clinical service provision and provide accessible specialist care at a population level.
A report from the Royal College of Physicians (RCP) on integrated care, due later in 2015, includes contributions from clinicians practicing in a variety of specialties, as well as from a cross-section of consultants and GPs involved in medical and specialty training, patients, trainees and senior policy makers, all addressing what steps need to be in place if integrated care is to deliver the intention envisaged in the NHS five-year plan. Ahead of this publication, we summarise insights gained from our preliminary work.
What is integrated care?
In a 2009, a systematic review of 326 peer-reviewed papers identified 175 different definitions and concepts of integrated care.7 In a 2011 joint report to the Department of Health by the King's Fund and Nuffield Trust, integrated care was defined as ‘an organising principle for care delivery that aims to improve patient care and experience through improved coordination’.4 Differences in understanding and interpretations of integrated care can be a significant barrier towards its development. The RCP approached colleagues and patients from around England seeking what they considered to be the key ingredients (and where possible examples) of integrated care. Many responded with similar themes, detailed in the report. Perhaps Mr Michael Morton, co-chairperson of the Embedding Partnerships Lay Partner Advisory Group in north-west London, provided the most understandable and concise reply to our enquiry, in defining integrated care as ‘working across organisations, together with patients and users as equal partners, and with the patient and population at the centre of the focus of care’, a definition similar to the joint statement on integrated care.8
Why is integrated care needed?
The NHS is facing a number of challenges from various directions, as highlighted in the 5 yr FV.5 Connecting care between services, organisations, systems and individuals through new ways of working hopes to address these challenges.
The ‘triple integration agenda’ between (i) primary and secondary care, (ii) physical and mental health services and (iii) health and social care is highlighted as the model of care to enable people with complex health and social care needs to live healthier and more independent lives.5 The above integration will hope to deliver improved patient care, patient experience and reduced fragmentation through better co-ordination of care across services and multidisciplinary team work. The aspiration is to deliver a cost efficient healthcare system for the increasing number of patients with long-term conditions and older patients with complex medical and social needs.
A hurdle in gaining universal acceptance of this agenda among medical professionals is the lack of a strong evidence base supporting what is a resource-heavy exercise.9,10 However the general consensus that this should be the direction of travel is powerful, especially given the apparent support of patients and patient groups.1
How can integrated care be delivered?
It is clear that there is no one-size-fits-all model of integrated care, and transferring those used elsewhere without a full understanding of the complex local landscape does not always work. Certain key elements are required, including a shared long-term vision, focused around both the patient and population needs, good communication through shared IT, clinical engagement via multidisciplinary team working, strong clinical leadership and clinical governance to ensure accountability through performance measurement.6,11,12 Key ingredients drawn from our work thus far on the RCP integrated care report are summarised in Box 1.
Box 1. Key ingredients for the medical specialist in delivering integrated care in medical specialties.
How can we share the same vision and achieve true integration without integrated budgets?
While collating views from across different settings, it became clear that competition and contracting can lead to conflicting intentions between different care providers. To encourage out-of-hospital integrated care, the 5 yr FV encourages commissioning tariffs to be based on health outcomes at the population level rather than the individual patient activity level.5 The plan also highlights the strength of commissioning from a single umbrella organisation formed from partnerships between different provider groups that should include hospital specialists, GP practices, and other community health and social care teams.13 Provider groups working together under a single umbrella organisation would then need to share the same long-term vision for how best to develop and deliver locally based clinical services working on communally agreed healthcare outcomes.
What it means for hospital services? – more than just community clinics
Hospital services of the future will share responsibility for the wellbeing of the population through flexible and improved working with primary and social care providers. Services will be centred on maximising the ability of the specialist consultant to reach out to patients in different physical and non-physical (eg electronically) settings and to support primary care via innovative ways.6,12 Education will be essential, both for patient self-management and also for training of the primary and community care workforces. Multidisciplinary team community case management and care planning will be key objectives in caring for complex patients at home.14 This move of planned non-acute work outside the hospital walls will enable those doctors working in the hospital to better support 24/7 acute medical services, as outlined in the RCP Future Hospital report.3
Role of the specialist medical consultant: bringing and supporting high-end specialist care to different settings
The medical specialist must play a central role in leading and delivering integrated care.11,12 The RCP report on integrated care highlights a range of roles the specialist workforce of the future will need to undertake, summarised in Box 2. Strong leadership skills will be vital to influence change across organisational boundaries.
Box 2. Role of the specialist medical consultant.
Next steps: RCP integrated care report and urgent changes needed in medical consultant training and support
Before the aspirational goals of integrated care can be achieved, changes in how and where we work and are supported as medical specialists will be needed. Urgent changes are needed in medical education, specialty training and job planning to equip and support the consultant force of the future if they are to lead in delivering care across organisations with a strong patient-population focus. Details of this are highlighted in the full report.
Conclusions
The NHS 5 yr FV provides an opportunity for secondary care consultants to participate fully in designing future specialist services. Taking a proactive approach now with local community providers and CCGs will be in the best interest of our patients while allowing our clinical specialties to flourish.
The future medical consultant will need to be a supported and empowered specialist who can deliver high quality and accessible care and support, focused upon meeting the needs of the patient and population, aiding other health professionals via integrated care services in a variety of sectors and using a portfolio of methods. The gaps in training and job planning are urgent priorities that must be immediately remedied if we are to move forwards in this direction.
- © Royal College of Physicians 2015. All rights reserved.
References
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- National Voices
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- NHS Future Forum
- 3. .↵
- Future Hospital Commission.
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- Goodwin N
- 5. .↵
- NHS England
- 6. .↵
- Naylor C
- 7. .↵
- Armitage GD
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- Royal College of Physicians
- 9. .↵
- RAND Europe, Ernst & Young LLP
- 10. .↵
- Bardsley M
- 11. .↵
- 12. .↵
- Robertson R
- 13. .↵
- Ham C
- 14. .↵
- Ross S
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- Introduction
- What is integrated care?
- Why is integrated care needed?
- How can integrated care be delivered?
- How can we share the same vision and achieve true integration without integrated budgets?
- What it means for hospital services? – more than just community clinics
- Role of the specialist medical consultant: bringing and supporting high-end specialist care to different settings
- Next steps: RCP integrated care report and urgent changes needed in medical consultant training and support
- Conclusions
- References
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