Putting patients at the centre of coordinated care is the foundation of the integration agenda. But how can we turn that ambition into practice? Daloni Carlisle reports
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Now that integrated care is truly on the agenda and a must-do item for NHS organisations, the question is: are they really putting the patient at the centre?
The notion that integrated care must be person centric is one that has bubbled up slowly to the point where it is an accepted doctrine.
It is there in all the policy documents, from the King’s Fund and Nuffield Trust’s work, as well as that of National Voices.
All of these have influenced the NHS Five Year Forward View, which in turn is driving new models of integrated services.
‘It is encouraging that the narrative we produced on person centred, coordinated care has been enthusiastically adopted’
As Don Redding, director of policy for National Voices, says: “It is encouraging that the defining narrative that we produced on person centred, coordinated care has been enthusiastically adopted by the systems leaders and pioneers.”
He sees a wide range of organisations starting their integration journey by developing vision statements based on this narrative of putting patients, families and carers at the centre of services.
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The conversation has moved beyond policy forums and out into the NHS.
“The advent of clinicians in commissioning has enabled that,” he says. “It is a way of thinking that enables some common ground to be established in terms of setting goals between commissioners and providers and what each wants for patients, what people want for themselves and what commissioners want of multiple providers.”
“To try to achieve the things that are envisaged, you have to take on system and structural processes”
He is cautious, though, about how quickly these vision statements can be translated into truly innovative, person centred services.
“To try to achieve the things that are envisaged, you have to take on system and structural processes,” Mr Redding says. “You need to change to produce the outcomes you want.”
And that is hard work with the rewards often some way down the line. It is easy to lose sight of the vision in the process.
“It’s a five or 10 year process,” he says. “We are by no means secure in our confidence that the reconfiguration of local jigsaws of services is going necessarily to produce better services for service users.”
Nicola Walsh, assistant director for leadership at the King’s Fund, agrees that the defining narrative of integration is person centred care.
That is partly because it is the way in which organisations on the integration journey have overcome barriers, she says.
“When you talk to the people who have already set up integrated care, they say that whenever they came across barriers they always went back to the patient because that was the shared goal around the organisations.”
It is a lesson others are taking on board, Dr Walsh argues.
‘We are working here on a model that is about patients and families and carers at the centre’
But again, she agrees it is not easy. “Health policy for the last 10-15 years has created independence at an organisational level and we have a mindset in health that identifies with organisations.
“When leaders in this system say they want to take risks and work in a different way, they may well agree in principle but at the end of the day, those individuals still report back to their individual boards.”
Pride of place
She argues that the shift to patient centred care will require system leadership with some incentives that support leaders to take much more of a place based approach. It will also be beneficial to devolve some of their leadership to patients and service users.
To support this, the King’s Fund has recently appointed two patient leaders and developed the Leading Collaboratively with Patients and Communities programme.
“It has brought GPs together into a community interest company”
At the coalface, Mel Pickup, chief executive of Warrington and Halton Hospitals Foundation Trust, says thinking in her area is firmly informed by patient centric care. “I think as a starting point it is absolutely right,” she says.
“We are working here on a model that is about patients and families and carers at the centre, with services that wrap around them in concentric circles.”
But fine words will surely butter no parsnips. Delivering the vision means using a new way of thinking altogether to inform choices about organisational form (mergers into a few providers or many collaborating with each other, for example), understanding where accountability lies and investing in the right means to integrate healthcare (for example, in IT that delivers shared information).
In Warrington, partners are working on a population based model in which GPs responsible for the care of around 30,000 people cluster and orient services around that population.
Within each conurbation, GPs stratify patients by risk to identify those most vulnerable, who are offered targeted support by multidisciplinary community based teams.
“What we are talking about is an accountable healthcare system based around the GP list,” says Ms Pickup.
‘The hospital’s role in this model is really to examine and question the services we provide’
Where is the hospital in all this? She explains: “We see our future role in this model being really to examine and question all the services we provide and ask: does this have to be provided in secondary care by virtue of clinical co-dependencies, critical mass, economies of scale or of equipment – or can it be provided out in the community?”
If services can be provided in the community, then what are the means? Telehealth and shared patient records will likely be key components - and recently the local authority procured a new IT system with a view to this in future: its unique identifier for residents is their NHS number.
But coming back to Ms Walsh’s point that putting the patient at the centre is what helps organisations overcome barriers, Ms Pickup says: “It has brought GPs together into a community interest company.
“What we are now finding as acute providers is that we have a relationship with them that is outwith the CCG and is one of fellow providers.
“If we can come together with a range of providers to take more patient oriented decisions, this can be a catalyst for describing what the future will look like and how we will get there.”
Philippe Houssiau on prevention
One of the most significant challenges facing healthcare in the 21st century is the growing prevalence of diabetes. A recent Health Survey for England found that up to a third of the population is in a pre-diabetic state.
This represents a huge burden on the NHS -with NHS England estimating that diabetes care accounts for approximately 10 per cent of total health resources, predicted by others to rise to over 17 per cent in the next 20 years.
It’s because we are focusing on traditional disease treatment, rather than prevention.
Research has shown that active management can halve the number of people transitioning from a pre-diabetic stage into a diabetic stage. Minimise the number of people who transition into a diabetic stage, and many would never need an acute care facility.
This is where active population health management comes into play – designing care pathways that cross primary, secondary and tertiary care and into lives, topped with a health analytics framework providing relevant, accurate and predictive data – at the point of care.
How can we make this work? Awareness is key – most of those with diabetes or pre-diabetes are not aware of their condition.
Early detection is vital – once people are identified as being at risk, interactive tools can be provided, allowing individuals to monitor their vital conditions, and preventative and care programmes can be fine tuned to help maintain or even reverse their condition.
If we then capture data – making it relevant for monitoring, risk stratification and predicting outcomes – that will really make the difference. That is exactly what coordinated care is about.
The real power is that it can be scaled to health economies, analysing details on a population level. If diabetes can be managed across a region, that’s when we will see the real value in this approach.
I believe that this move to early wellness and disease prevention will have as profound an impact on healthcare economies in the 21st century as the ability to treat certain diseases did in the 20th century.
It’s the model that the most forward looking health economies are moving towards, as the Trafford Clinical Commissioning Group’s Patient Coordinated Care Centre will illustrate (see case study, overleaf).
Ultimately, it’s a model that will help sufferers of chronic diseases remain in a pre-clinical stage, allowing them to live better quality lives.
Philippe Houssiau is vice president of healthcare and life sciences at CSC
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Integration supplement: Patients first must be the focal point