Integrating care: overcoming the barriers

The NHS is currently experiencing the largest-scale structural change in its history, with the transfer of commissioning responsibility from Primary Care Trusts (PCTs) to Clinical Commissioning Groups (CCGs) and the NHS Commissioning Board, and responsibility for public health moving out of the NHS to local authorities. Meanwhile, at local level, service re-organisations and reconfigurations continue as the NHS strives to improve care pathways, concentrate specialist services in centres of excellence, deliver more care in communities rather than acute hospitals, strengthen integration with social care, and provide more personalised services. More and more people are living with long-term conditions such as diabetes, coronary heart disease and respiratory diseases, and multiple co-morbidities. As the population ages, we are also seeing a rise in conditions for which age is a major risk factor, such as dementia. In addition, one in four people experiences mental health problems at some point in their lifetime. While NHS services are available for everyone, regardless of age or the care they require, older people are accounting for a bigger proportion of NHS hospital activity every year.1 The Spending Review, last month, has given £3.8 billion to help older and disabled people for 2015/16. It is designed to provide support for older and disabled people to stay out of hospital and reduce in-patient care requirements. Sir David Nicholson described this sum as a ‘game changer’ so that opportunities can be taken to accelerate the development of integrated services. It means that more joined-up care can be provided for patients with complex needs, enabling them to be supported at home. We must therefore find a suitable way for quality care to be delivered in a safe environment, wherever that may be, in which the patient shares some of the decision making and enjoys a smooth and co-ordinated journey. At the same time, we must also recognise that the provision of high quality care is an inherently complex and fragile operation. Quality is systemic – the patient journey cuts across primary and secondary care, health and social care, and involves multiple professionals. Therefore, it is a collective endeavour, requiring collective effort and collaboration at every level of the system.2 One of the possible mechanisms, while not new, which is attracting considerable attention at present, is that of integrated care. Integrated care is perhaps a means to an end – the end we seek being an improved patient experience, at the same time improving health outcomes, delivered efficiently and effectively.

Integrated care

What is apparent, from reading much of the current and historical literature available on the topic, is that there is no easy solution. While integrated care has been planned, debated and discussed for many years, and some pilot projects run, there are some fundamental barriers to its ultimate success in the infrastructure of healthcare in England. It is also true that there are currently a number of political initiatives which may remove some of these blocks, enabling a broader spread of pilot projects to emerge. So what exactly is ‘integrated care’? The World Health Organization’s definition seems to be the one most often quoted: “The organisation and management of health services so that people get the care they need, when they need it, in ways that are user friendly, achieve the desired results and provide value for money.” The NHS Outcomes Framework also specifies all the principles of integrated care and moves the issue from being a theoretical concept to a set of five domains which translate into deliverables for patients. NHS Midlands and East identify that, when integrated care is spoken of, it means four things.3 These include: pathway integration, organisational integration, information integration and incentive integration.