National leaders must act faster to change the payment mechanisms in the NHS, to allow more respiratory care to be delivered in the community, writes Binita Kane.
Outcomes for respiratory disease across the UK are amongst the worst in Europe. We recognize that people with long-term respiratory conditions are often diagnosed late and not supported to engage in the lifestyles that will keep them well.
They are often on multiple medications which have not been optimised, and experience repeated crisis-driven hospital admissions at huge cost to the healthcare system and their well-being.
In addition, it is well documented that tobacco addiction, mental health problems, loneliness and other social determinants of health are major drivers of healthcare utilisation in this population.
Many of these factors contribute to winter pressures in the four nations of the UK with the resulting impact on all aspects of both non-elective and elective care in the NHS and also social care sectors.
NHS England’s national collaboration for integrated care and support states “for health, care and support to be ‘integrated’, it must be person-centred, coordinated, and tailored to the needs and preferences of the individual, their carers and family.”
There is a requirement for strong clinical leadership from secondary care specialists to work both with and within ICSs
The long-term plan states that integrated care systems will be central to its delivery and that by April 2021 ICSs should cover all of England. We wish to support NHSE in realising this vision by changing the current medicalised reactive model of care, which is no longer fit for purpose, to a continuous community team-based proactive system that can work with patients and communities to self-manage.
In order to achieve this, there is a requirement for strong clinical leadership from secondary care specialists to work both with and within ICSs.
By moving the respiratory specialism outside of hospitals, we can support primary care in delivering preventive and proactive care as intended by the key elements of the LTP. There are excellent examples in other long-term conditions such as diabetes, where this way of working has improved outcomes for patients and reduced demand on acute trusts.
However, secondary care consultants need dedicated time to build and develop the relationships required at ground level to enable change and should be supported in this by the healthcare system.
Collectively, those of us trying to drive forward these changes are facing difficulties. The way the system is set up does not empower or enable us to achieve our goals.
Barriers to achieving LTP ambitions
In sharing our experiences, we have realised that across the country we are encountering the same barriers. Acute trusts are not supporting consultants to have job-planned time to lead integrated care, counter to the ambitions of the LTP.
There are multiple reasons for this. Despite tentative moves away from tariff, the payment policy still encourages acute providers to expand activity within hospitals rather than across the care continuum.
Acute trusts are still incentivised to continue providing services that are based on episodes of care rather than integrated clinical pathways. The regulators (Care Quality Commission and NHSE/Improvement) still focus on episodic or single-organisation care and do not encourage integration.
Acute trusts are still incentivised to continue providing services that are based on episodes of care rather than integrated clinical pathways. The regulators (CQC and NHSE/I) still focus on episodic or single-organisation care and do not encourage integration
There is also a lack of core training in integrated care, population health and leadership training within medicine such that development of integrated care is reliant on enthusiastic individuals rather than because the system demands or drives it.
We welcome the LTP, which has given a blueprint for addressing all aspects of suboptimal care for people with long-term respiratory conditions and a vision of how to enable us to have the best respiratory care in the world, but are concerned that progress will be thwarted unless cross-boundary working is facilitated.
Yesterday, a group of 54 clinicians including the outgoing national clinical director and chairs of the British Thoracic Society and Primary Care Respiratory Society, wrote a letter to NHSE’s executive team, with a plea to remove perverse payment incentives and to tackle the obstacles in the system.
We ask that acute trusts are incentivised specifically to anticipate the LTP ambitions and to give us the support and tools we need to deliver the changes required. Unless this can be achieved, delivery of the plan may simply be a pipe dream.
Binita Kane is a respiratory specialist and co-chair of Respiratory Futures Integrated Care Network, a national group of consultants, GPs, nurses and allied health professionals.