The writing's on the wall for fragmented care

The writing's on the wall for fragmented care
posted 06 May 2014

Claire Kennedy, senior adviser at Integrating Care, wrote an article about integrated care which appeared in The MJ last week. Thanks go to the features editor, Jonathan Werran, for his kind permission to reproduce the article here.

A link to the original piece in The MJ can be found here:


The changing landscape of care has been high up on the news agenda of late, with more and more people adding their voice to the collective call for an approach that puts the patient at the centre of their care. Local authorities’ Better Care Fund plans were submitted in April, generating a lot of media attention – not all of it positive. 

The Labour Party Commission on Integrated care, chaired by Sir John Oldham, published its report on Whole Person Care in March, and the first day of April saw the inauguration of Simon Stevens as chief executive of NHS England, where he pledged to transform how care is delivered outside hospitals.

Whether or not you agree with the current means touted to achieve care integration, it is clear that this is not an issue that is going anywhere anytime soon. The fact is that people are living longer.

While this is to be celebrated, it also brings new challenges. The proportion of the population living with multiple conditions is at a record high and is set to rise yet further in the years aheade, given the increasingly aging demographic. 

What’s more, independent living is more possible and more of a priority for today’s elderly generation, and their care delivery has to reflect that. We wouldn’t expect medicine itself to stay the same, so how can we expect this of the organisation of care?

Indeed ‘care’ encompasses a great deal more than just the treatment of poor physical health and assisting those experiencing it. The interplay between mental and physical health issues is also becoming ever more apparent; one very much feeds into the other. Treating them as mutually exclusive problems with entirely separate care pathways is in the best interests of neither the service-user nor the economy.

Previously, the suggestion that economic considerations are the key driving force behind integration has been the key criticism of the movement. Certainly an integrated approach makes more efficient use of existing resources and this is to be welcomed.

However, the positive impact of people feeling like they are more in control of their own care – and that those delivering the care are acting as one team – is invaluable. Simon Stevens summarised the symbiosis between service-user experience and economy neatly, when he advised healthcare workers to ‘Think like a patient; act like a tax-payer’.

As we’ve seen, healthcare workers are just one fragment of a much wider web when it comes to holistic care. For a joined-up approach to work, the responsibility is not solely in the hands of national services, nor is it solely a local government issue; we must see true collaboration and alignment of purpose at the national and local level. Indeed, as has been well noted, there are a great number of fantastic local coordinated care projects already in operation.

The challenge now is to take what has been learned from these initiatives and make whole-person care work at scale.

Our work at Integrating Care, with the Local Government Association (LGA), has aimed to address this very challenge. Using the example of existing projects, we developed a toolkit to help other local areas come up with a plan of action to realise a co-ordinated approach in their area.

We were aided by input from literally hundreds of professionals, service users and carers in this endeavour, and have tried to present the tools in a way that is easy to navigate and understand.

As part of this, we drew up a number of ‘Value Cases’ evidencing the positive impact of these initiatives – from a service-user, deliverer and financial perspective – in the locales in which they were undertaken.

Another of the tools – the interactive ‘Benefits Model’ – collates all the hard data on these interventions and allows local service designers to play around and get an initial understanding of what impact various models of care might have if they were applied to their own local population.

The changing demographic and the corresponding evolution of our care needs have made sticking our heads in the sand with regard to service integration impossible.

Facilitators like the LGA toolkit can certainly help, but ultimately the success of realising whole person care is dependent on changing attitudes, management, and behaviours. There isn’t a moment to lose.


Successful Integrated Care Programmes

These summaries of localised integrating care programmes do a good job of demonstrating the joined-up approach to healthcare in practice.

The WELC Integrated Care Programme covers Waltham Forest, East London and City (WELC). It started in autumn 2012 and consists of multiple partners, including councils from the three boroughs of Newham, Tower Hamlets and Waltham Forest. Its aim is to target those with long-term conditions, the elderly and those with mental health problems in the most deprived areas of London. 

The programme was designed around five key areas, namely information sharing; evidence-based pathways and care packages; joint health and social care assessment; creation of new roles within the provider workforce; and organisation of practices into networks. But what was it that enabled these to be made a reality?

Openness is encouraged across the three boroughs, allowing the sharing of best practice, even though each borough is progressing at a different rate. The voice of service-users will be instrumental in shaping the care packages, and patient representation is being implemented with the Integrated Care Boards. Some of the boroughs are planning activities to track patients' perceptions of their care, which will further embed patient-centred care.

On the joined-up health and social care front, the project managers have created a joint WELC steering group to bring commissioners and providers together across the whole system. This joint structure has brought coherence to the programme and involved providers in discussions and decision-making where possible, from the start.

The boroughs of the WELC programme are at different stages of setting up network meetings between GPs. These allow local views of patient trends, and provide the foundation for meetings between GPs, hospitals, social services and community services, which in turn are helping providers find ways to collaborate.

The programme is being evaluated, but getting agencies to share information, having a single point of contact, organisational development, relationship-building and leadership at all levels have emerged as being crucial ewhen putting integrated care into practice.

A second example of integrated care in practice is the Northamptonshire Frail Elderly programme. As the county has a growing aging population and low rates of patient independence after hospital admissions, Northamptonshire Integrated Care Partnership started a project aimed at people aged 75-plus. The overall aim of this programme is for a healthier, more independent elderly sector in the county.

Initial problems identified ranged from a lack of awareness among health and social care providers of the existing services provided by the community, to a reluctance to share risk between commissioners and providers, and the need of patients for ongoing encouragement to attend exercise programmes or self-help groups.

The Northamptonshire Frail Elderly programme is putting a range of changes in place, such as introducing locality-based multi-disciplinary teams to manage people's long-term conditions and a community geriatrician-led crisis response team. Crisis management is being re-routed through a co-ordination hub, rather than relying solely on A&E admission. This enables the geriatrician and integrated team of health and social care professionals to work together to support patients in crisis in their home environments. 

Although this programme hasn't even reached its first birthday, some positive outcomes have already been recorded. Greater numbers of service-users are being treated in the community, frontline staff have reported having greater confidence and Northamptonshire CC has re-invested funding to provide additional care managers. Most importantly, patients have said they are happier.