An integrated care pilot in London is linking up services for people with complex health problems and social issues. Andrew Steeden and Aumran Tahir demonstrate the benefits.

Ensuring that patients receive integrated care was featured strongly in the government’s response to the NHS Future Forum. The duty to promote integrated health and social care will be required for both clinical commissioning groups and the NHS Commissioning Board.

But what does integrated care mean in practice – and how can it work?

NHS patients and their carers often say they are frustrated when they have to repeat their story to lots of different doctors. On its part, the NHS finds it difficult to identify patients with a high risk of emergency hospital admission. Without easy access to a single view of patient medical information it is difficult for clinicians to get together to discuss complex patient needs. This makes decision making less than ideal, preventing effective monitoring, coordination and comparison of performance between peers.

As more people develop long term conditions or serious medical problems and patients’ use of hospitals continues to grow three to four times more rapidly than population growth, the challenge is to improve quality, especially patient outcomes, while reducing costs.

So it makes sense to target the care of people with diabetes and those aged over 75, who represent 10 per cent of the population and 28 per cent of budget in north west London with a new initiative to improve integrated care.

The integrated care pilot in north west London adopts an innovative approach to the care of patients who often have complex health problems and related social issues.

The pilot builds capability for primary, community, social care and hospital healthcare services to work collaboratively and safely support people at home, so reducing unnecessary hospital stays. It plans and coordinates care across settings in five boroughs serving an initial population of 383,000 people and aspiring to serve 750,000 residents.

If one emergency admission could be prevented per month for each participating GP this could save the local health service £14m a year and release this money to invest in community based services.

The pilot addresses major issues that normally prevent the delivery of widespread integrated care. These are: a governance structure so all organisations share and work to the same objectives; financial incentives and work within agreed guidelines; IT that supports integrated care; sufficient scale – in this case two large hospital trusts, community services, more than 100 GP practices and five local authorities all overseen by patient representatives. We have overcome the four main barriers to integrated care (see table, below).

A real opportunity: what this means for people with diabetes

Dr Jonathan Valabhji, consultant physician and diabetologist, Imperial College Healthcare Trust

Diabetes now affects around one in 20 people in north west London and this continues to increase.

The feared complications, such as blindness and limb loss, can be prevented through effective management from diagnosis. Self-management is a crucial component, and collaborative care planning puts our patients very much in the driving seat.

While the diabetes work under the Healthcare for London strategy provided a framework for delivery of high quality care it has so far only proved possible in pockets across north west London.

The integrated care pilot provides a real opportunity to deliver high quality integrated care to all those with diabetes, including those that have traditionally found it difficult to access NHS services. With providers working closely together, patients can move seamlessly between the different provider settings, so that the right care can be delivered in the right place at the right time.

Less disruption to patients’ lives: what this means for people aged over 75

Dr Iñaki Bovill, consultant physician and geriatrician, Chelsea and Westminster Hospital Foundation Trust

The main potential benefit of the integrated care pilot for older people is the effective IT tool which will put patients at the heart of their care. For the first time we can create an individualised care plan for each patient which all health and social care professionals involved in their treatment will be able to access.

Improved case management to link all the services together will help prevent duplication of clinical investigations and mean less disruption to patients’ lives by ensuring that everyone involved in their care is in the loop.

Creating a care plan for a frail elderly patient can prevent them sliding down the scale and wherever possible avoid emergency admissions to hospital and help plan discharges from A&E and hospital wards more effectively.

This is vital because a prolonged stay in hospital increases the risk of older patients becoming frail, being put at risk of hospital acquired infections and losing their confidence.

Last year more than 6,000 patients aged over 75 were admitted to Chelsea and Westminster Hospital as emergencies which is why the pilot has such a key role to play in improving preventive care of older people.

New way of working

At the heart of the pilot is the planning and coordination of care across patient settings by multidisciplinary groups. These groups include GPs, acute consultants, community specialists, mental health clinicians and social care professionals. They work together in local groups supported by representatives from all providers who are held jointly accountable for delivering care.

An innovative IT tool was developed to help the multidisciplinary groups to:

  • proactively plan care by identifying high risk patients using population segmentation and risk stratification;
  • coordinate and plan care for patients (sharing these plans across settings) and monitor progress;
  • view patient medical information from multiple settings;
  • spread best practice by tracking and evaluating the performance of GP surgeries and multidisciplinary groups.

At a time when the NHS is under pressure to reduce costs, integrated care could provide the opportunity to develop services which still deliver better patient outcomes while also releasing efficiency savings. In north west London we are already embracing a new way of working together in which GPs work alongside specialists to deliver integrated health and social care that is both patient and clinician driven.

Robust evaluation will be conducted at the end of the pilot year to track impact.

Our advice to others developing integrated care is to make sure providers come together to tackle the barriers to providing seamless integrated care to patients.

Overcoming barriers

Barrier to integrated careOur solution
Lack of joint working by all providers on a patient pathway
  • Set up multidisciplinary teams including primary, community, mental, social, voluntary and acute representatives covering around 50,000 patients. There are nine teams up and running in the pilot
  • Established provider governance for the pathways by forming a non-incorporated association in which all providers are “shareholders”
Lack of alignment of financial incentives
  • Devised a funding model that rewards clinicians and organisations fairly for the costs of providing care
  • Agreed a system whereby commissioners and providers share the financial gain if the pilot exceeds its objectives
Difficulty in sharing information between providers

Developed an IT tool that enables providers to:

  • risk stratify patients
  • generate care plans including work lists for providers and share the care plan
  • view a summary patient record across all pilot providers
Inexperience of clinicians working in multidisciplinary environments
  • Organisational development including developing a DVD of a multidisciplinary case conference and investing in simulation training

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