The forward view and Dalton review have upped the ante for greater integration of health and social care but 2015 presents challenges, writes Ros Ashcroft
Failure or success road sign
Integration has been on the agenda for the health service for years, but 2015 could be the year we see real moves by some organisations to work in more formal partnerships with others from the health and social care sector.
With the NHS Five Year Forward View, and the recent review from Sir David Dalton published towards the end of last year, there is significant momentum behind the latest drive towards major restructuring of services to drive up quality, efficiency and patient satisfaction.
Greater integration in health and social care is vital in achieving these goals but, with the final shape of integrated services as yet uncertain, there will inevitably be challenges to be faced and overcome.
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Healing the fractures
Patients and carers are angry that the patient journey is far too fragmented and are frustrated at having to repeat their histories.
Many people do not understand the divide between free NHS care and means tested social care. NHS leaders we have spoken to agree that change is urgently needed.
‘Some believe there should be a default setting allowing multiple morbidity patients’ data to be more widely available’
Some commentators feel that, for patients with multiple morbidities or conditions requiring contact with several services, there should be a default setting that means their clinical data is more widely available.
This would be a practical way to avoid repetition and frustration on both sides.
Brand the condition
Integration can help redesign systems around the patient or condition, rather than around organisations providing care or treatment. For instance, the Brighton and Hove Integrated Care Service has created Care Beyond Boundaries, which brands services – anxiety, depression or musculoskeletal – rather than the organisations providing them.
“People are very dissatisfied,” says executive director of the service, Zoe Nicholson.
‘Our ambition is to create a service organised around people’s goals’
“They have growing expectations that they should not have to be assessed and reassessed and tell their story to three, four or five different people in a week,”, adding that the care community needs to go further.
“We need to support and empower people to be the expert patients that they are; empower them to utilise the resources that are available to them, from the NHS and other providers.
“Our ambition is to create a service that is organised around people’s goals.”
But Julian Emms, chief executive of Berkshire Healthcare Foundation Trust, says that the problems start with the systems providing care in its widest sense. “People are, generally speaking, most grateful for their healthcare but… people do not understand the divide between an NHS free at the point of use and a means tested social care service, especially when it’s the same team providing those bits.”
The system is too complex, he claims.
“I have 15 commissioners in my area: there are seven clinical commissioning groups, six local authorities, NHS England and three regulators. Getting 15 people round a table is hard enough, and you can spend a fortune getting governance arrangements in place that satisfy all of them.”
According to Mark Spencer, the NHS Alliance new provider network lead and a GP in Lancashire, the “very fragmented” state of care is one of the reasons people dial 999 or attend A&E.
“It’s crazy that this has not been sorted,” he says.
‘You can spend a fortune getting governance arrangements in place that satisfy all stakeholders’
“You still have a system where one person prints out pieces of paper and hands them to another person in another organisation who manually inputs them into a computer.
“We need to establish a system where a person who goes to the pharmacist with an eye infection gets the same service as if they attended A&E; there are algorithms for this sort of thing.
“If you phone the practice complaining of breathlessness, you should expect the same consistent algorithms and not have the receptionist telling you to dial 999.”
Muhammed Ali, clinical director of the North West London Integrated Care Programme which integrates care across eight London boroughs, says that part of the problem is how structural changes, such as downsizing hospitals by centralising for high quality patient care, are interpreted.
“We have had a number of recent closures of A&E that have been publicly translated by the media into ‘hospital closures’ and, hence, the
tortuous challenge undertaking these changes.”
Arrange care around people
But Thirza Sawtell, director of strategy and transformation for NHS North West London Collaboration of CCGs, puts an optimistic spin on the situation.
“We would find integration much harder if everyone was saying everything is fantastic. Our narrative is that we are going through major reconfigurations so that care can be provided in a more appropriate place. Therefore, we are organising care around people rather than around organisations. We like to give examples of changing care in this way rather than resorting to management speak.”
Information technology and data sharing are essential to enable seamless care across organisations yet remain some of the most challenging areas, said Anne Crofts, a partner at DAC Beachcroft.
“The Law Commission’s recent report on data sharing, following a public consultation, recognises that law reform is needed to clarify the legal framework for sharing data among bodies delivering public services,” she says.
“There is little evidence that unlawful or improper sharing is a significant issue among such bodies. Data breaches reported to the Information Commissioner in the health sector tend to be accidental data security incidents rather than issues about the legal basis for deliberate data sharing between organisations.
‘Concerns about data security is impacting on organisations’ confidence about data sharing’
“There should be no legal reason why members of care teams drawn from multiple organisations can’t currently share patient data in order to provide care to that patient, although clearly there must be safeguards around the sharing process to preserve public confidence.”
Ros Ashcroft, an DAC Beachcroft associate, has worked with health and local authority clients to prepare a response to the Law Commission’s consultation.
“It was clear that general concerns about data security and the use of data in society are impacting on organisations’ confidence about planned data sharing.
“We were also struck by comments about the lack of understanding of information law and governance at senior levels in organisations. This is impeding the ability of organisations to identify potential data management issues early on in discussions about integration, and to ensure that they are factored into the structure of a project, and that practicalities are worked through the technical legal framework. Yet these are the steps that are required if data sharing issues are not to become obstacles to effective integration.”
There is concern that difficulties in agreeing frameworks for data sharing will increase when new EU data protection legislation takes effect next year.
Ros Ashcroft is an DAC Beachcroft associate