Integrated care needs the clinical-managerial marriage to work

The Future Forum did the NHS a great favour in re-establishing integration as a key enabler for better healthcare. Next to the financial sustainability of healthcare systems, integration is the most talked about topic in healthcare.

Whether it is Medicare locals in Australia, accountable care organisations in the US, integrated care organisations in the UK or integrated care service reform in Singapore, most countries are experimenting. If the hospital represented the temple of healthcare in the 20th century, “e-enabled” integrated care will surely be its high priest in the 21st.

In the The Innovator’s Prescription, Clayton Christensen argues that healthcare models are out of date because we have conflated two business models which are no longer fit for purpose; namely the general hospital and primary care practice. He argues that the lack of innovation results in sub-optimal care and costs.

Given that 80 per cent of all GP consultations and two thirds of emergency admissions are related to patients with long term conditions, he adds that “the system has trapped too many disruptive-enabling technologies in high-cost institutions that have conflated two of three business models under one roof”. Integrated care could change this if NHS reform is managed well.

Indeed, the NHS next stage review in 2008 launched 16 integrated care organisation pilots that were led by GPs and hospital based clinicians. The pilots were to last for two years and their conclusions should now have been published. The delay has partly been due to the changing nature of the Health Bill and the artificial polarisation between integration and competition, but spreading learning now is crucially important as clinical commissioning groups are established.

A clinical analytics organisation, the Oak Group, has recently reviewed its work in 41 NHS trusts. It supports clinicians to look at their own admission and discharge protocols and models new patterns of care. The results present a compelling case for a change in our business models.

It has concluded that 22.7 per cent of hospital admissions could be cared for more appropriately in different settings. In nearly a quarter of all analysed admissions, care could be better provided at home, in intermediate care, in sub-acute care, nursing homes and community rehabilitation.

Seven ingredients

The reasons why it did not happen (in ascending importance) were because the patient was waiting for a social service assessment, waiting for a test result, poor documentation of the medical record, no alternative care setting being available and, most importantly, the clinical team had not actively considered viable alternatives.

Ironically, on case review, the most appropriate care setting was home with a follow-up GP or consultant visit.

Initially, current NHS reform was hesitant in prescribing integration as a potential solution but we now seem to be back on track. It would be wrong however to believe that simplistic structural reform is the answer. Few believe that attaching a non-local doctor and nurse to a clinical commissioning group is the answer.

The Commonwealth Fund and other research suggests there are seven key ingredients for success. Namely: inspirational clinical leadership; information systems that support care integration; the application of a robust clinical evidence base and improvement methodology; patient engagement; assistive technology; proportionate financial tariffs/incentives and a collaborative/innovative culture.

You’ll notice that none of the seven talks too much about structural change, which seems to be a particular preoccupation in the NHS.

Because of this focus, we might wonder whether we are paying sufficient attention to clinical leadership, clinical information and “bundled payment” mechanisms.

Integrated care organisations (run from hospitals or clinical commissioners) could be a very powerful force.

A tectonic change of this magnitude will require a new clinical/managerial relationship to develop. In this light, the recent presentation at the NHS Confederation on the excellent research into “NHS top leaders” makes for fascinating reading. It calls for “different leadership for a very different future”.

Praising NHS managers’ ability to “pace set” under direction, the research also suggests the NHS has not been creating the right constructive climate to move from an “old” operating model to a “new” one (which is hardly surprising given recent events). Only 26 per cent of leaders were identified with creating “high-performing and energising climates” and it went on to suggest that a new modus operandi would need to think about new “push and pull” incentives if current reforms were to deliver intended benefits.

When the House of Lords debates amendments to the Health Bill, 17 months will have been spent discussing reform. The strong managerial “must-do” culture in the NHS needs to be linked to clinical innovation between primary and secondary care clinicians if integration is to succeed in a sustainable fashion.

This requires much more than structures to be right. After all, culture always eats structure for breakfast.