Delivering integrated health services

Integration is the foundation of most high-performing health systems. It enables them to deliver consistent, goodquality care, particularly for populations with high-cost chronic conditions. Increasing numbers of commentators, including the King’s Fund, the Nuffield Trust and the NHS Future Forum, advocate integration – be it a formal merger of organisations or partnerships across bodies – as the key ingredient in meeting the financial and service challenges facing the NHS. To learn from high-performing systems it is necessary to assess more than just outcomes. It is structure and process that actually generate and sustain excellent outcomes. Get these right and the best outcomes should follow. The NHS focus on outcomes is often enabled locally by a data warehouse spewing out retrospective performance dashboards, which only enable the performance monitoring of two- to threemonth- old data and tracking national targets. But this can be a costly distraction from implementation and improvement, draining scarce management and clinical attention away from getting effective delivery structures and processes in place. It is like a sports coach, fixated on the score board, continually shouting to the team “We’re losing… Score!” and ignoring the processes that allow that to happen. Integrating care to deliver the best health management for a defined population involves various accelerators. All are necessary; none are sufficient on their own; and they are interdependent structures and processes. Sounds like a big job? Yes, but it is manageable. For most health economies integration will not require starting from scratch. Many of the accelerators will already be in place to some extent. The key is recognising and then filling the gaps identified by careful assessment. Issues can be tackled in any order to suit local context, with one exception. Integrated clinical engagement and governance are fundamental to success and need to be addressed up front.

Engagement and governance

Clinical engagement is structural, like the foundations of a building, and requires three elements: devolved decision-making; shared accountability; and rapid collaborative feedback. Existing governance frameworks need to be evolved towards a robust integrated clinical governance model. In creating its integrated care organisation by merging acute and community services, Southport and Ormskirk Hospital NHS Trust borrowed from Kaiser Permanente Colorado’s (KPCO) successful governance model. KPCO has the lowest bed-day use of all the Kaiser regions and was recently recognised by the National Committee for Quality Assurance as the best quality health plan for Medicare (over-65s). Southport created integrated care teams, each with clinical champions (GP and specialist co-chairs and a nurse) and a co-ordinator to facilitate meetings and ensure progress is supported between meetings. A committee of the Trust board was also formed (a clinical senate) to provide clinically led oversight of the teams’ progress. The senate is chaired by the chief medical officer and must have a set number of doctors in attendance to be quorate, although the Trust’s senior management team also plays an active part. Tough questions are asked and real progress has been made on service redesign, ways of working and engagement. Engagement has, in effect, been hardwired into the governance arrangements. Clinicians, especially doctors, are highly visible in the governance set-up and are accountable both to each other and to the board. Decisions simply don’t happen without the doctors’ involvement. The redesign process is accomplished within the teams and involves team members learning by doing clinical redesign and deployment activities. Monthly progress reports to the clinical senate give way to reporting on key process and outcome measures over time. Teams also have decision rights for redesign – clinical leaders take decisions with managerial input, not the other way around, and could receive devolved budget. The senate weighs up all requests and makes recommendations to the board.