Your views: Integrated services

How can we take advantage of the health and social care modernisation programme to ensure services are better integrated around people’s needs?

We are interested in your views in this area, including:

  • What does good look like?
  • Where should services be better integrated around patients, service users and carers – both within the NHS, and between the NHS and local government services? We are particularly thinking of social care – for example, better management of long term conditions, better care of older people, more effective handover of a person’s care from one part of the system to another, etc.
  • How can integrated services achieve better health, better care and better value for money?
  • What, if any, barriers to integration should be removed, and how can we incentivise better integration of services at all levels?
  • Who needs to do what next to enable integration to be progressed in a pragmatic and achievable way?
  • How can innovation in integrated care be identified and nurtured?

The NHS Future Forum’s work on integrated services is led by Geoff Alltimes and Dr Robert Varnam.

In NHS Future Forum | Tagged

12 Responses to Your views: Integrated services

  1. Dr John Hughes says:

    Integrated service provision is particularly appropriate for the most vulnerable – especially care of the elderly and patients at the end of their lives – the two groups increasingly overlapping. In the absence of any desire to integrate health and social care centrally the initiatives will continue to be at local level.
    The development of clinically-led integrated pathway design should be the first step with commissioners laying down their requirements for the ‘shape’ of integration and a framework in which relebvant providers should operate.
    Providers then need to come together under a ‘joint venture’ agreement or something similar so that the rules of engagement are clear and the relative responsibilities both to each other and to commissioners are transparent.
    A financial envelope needs to be agreed and agreement also sought on the relative risk and benefits attributable to providers and commissioners.
    Sound financial and qualitative outcomes need to be agreed up front and monitored rigorously.

    Competition can be used to establish partners in the ‘integrated care’ framework’ and also to select new providers if the establishes ones fail but competition should not be used as means in itself otherwise integration will be replaced by fragmentation.

    • Michael Vidal says:

      While not disagreeing with Dr.Hughes I would say that while care pathways should be clinically led they should be developed with the active involvement of patients who suffer from or have suffered from the condition that it is being sought to treat by the pathway.

      When I say active involvement I do not mean having a sole patient representative on the group developing the pathway I mean actively engaging with patients and seeking thier views on the way forward.

    • Integrated pathways with the patient and main carer at the centre remain just words unless the 4 elements you list are present. How do we offer comprhehensive geriatric assessment when someone is entering frailty? This needs to be expert and comprhehensive medical, social, functional and spiritual This applies to about 30% who are frail in population scanning programmes see http://www.staywell75.co.uk and then develop the integrated pathway. No pay for no appropriate service provision might see improved assessment in social service departments where my experience is that there is often duplication and procrastination that does not serve the patient but is a defensive response to perceived budget constraint. Breaking down barriers between medical and social and rewarding excellence in integrated working will improve the lot of the frail elderly and terminally ill.

  2. Catherine Lander says:

    Integration of services is crucial for any chronic or long term condition/difficulty. I work with children and I am very concerned with the difficulties families experince in getting the breadth of appropriate support they need and are entitled too. The increased number of providers from which services will be commissioned will make integration and flexibilty more difficult, the access to the NHS and Social Care appears to be getting more complex not less.

  3. jill says:

    very confussing for us very disbaled paitnets and trying to acess soical health care, localy nnew sytems we not infromed whats going on or if we get the care long term or is nhs funding still be here next mths so many like me with complex health soical care needs have a say and equality of care, not cut of acess to goods and serivces as it happneing now

  4. Bev B says:

    Time the NHS stopped being made to use ‘approved’ contractors which is a euphemism for masked bandits to supply goods and services. There is a competitive market out there – they need to take advantage of purchasing power and take control of their own finances instead of being pushed into contracts that end up costing taxpayers inordinate amounts of money for goods and services which are available cheaper and better elsewhere.
    Anyone in the construction industry knows about the abuse made of hospital funding for remedial, repair and maintenance work. Referring to a ‘hospital job’ automatically means higher work rates than anyone else and real rip-off treatment similar to insurance work where the prices are deliberately inflated to make sure the claim is as high as possible.

    Time to crackdown on all these illicit practices and send these cowboys packing.

  5. Jane Lewington says:

    In terms of integration of health and personal care one of the requirements is to build an integrated system focussed on supporting the individual to achieve the outcomes that are important to them. Easy to describe but very difficult to achieve. It can be done but the building blocks that have to be put in place to succeed in this journey are often under-estimated and the system sometimes does not have the patience to wait for the impact/results to come through. Integration needs to be driven by absolute clarity in how the individual will be supported to identify their preferred outcomes, active market development of integrated care options, care navigation for those who do not qualify for a formal care response and the use of direct feedback from serivce users on where professional or organisational barriers are still an impediment to achievement of thier desired outcomes

  6. George Ogden says:

    Integration for an individual can work for that individual where the individual has the knowledge of the system and /or the capability of developing that knowledge and the ability (personalised budget) to make the providers deliver what is needed.

    I agree that integration will benifit vulnerable groups (however you define the vulnerable) but for some of them, for whatever reason,personalisation will not deliver the benifits of integration. Benifits in this group will be delivered by integration of services within a health economy. Different patient groups and different health economies will have different comlexities but these complexities are hidden from these vulnerable groups and inceased quality of care and decreased cost of care are delivered.

    But we have a National Health Service and what i have desribed above is a a recipe for variation, Brilliant if it delivers, absolutely unacceptable if it doesn’t. But delivers what? Best care for individuals whatever the cost? or best care for individuals given a certain budget, accepting this is not the best? or is it best care for a population whatever the cost? or is it best care for a population given a certain budget? and is best care for an individual the same as best care for a population?

    Integation is an answer but what is the question? I have not heard a clear over arching National picture that can be locally interpreted and applied by health economies and individuals with same expection and agreement of outcomes.

  7. Anne says:

    The only way services can be integrated is if they work around the needs of the patient and the carer holistically and put them at the heart of any treatment or care.

    To achieve this it needs three changes – real information sharing and joint assessments with the patient and their carer; joint pots of money around the patents needs (not separate sources controlled by different agencies); an acknowledgement that patients and carers should be included at all levels of planning, decision making and care i.e. real co-production and personalisation.

    Patients and carers struggle with the systems that mean health professionals working with them do not share information about them with them and certainly do not share the information with each other. This is often because they use different systems to record the information and use data protection as a reason for not sharing. This is incredibly frustrating for the patients and waste time and resources for the professionals and the patient. If the patient can see, own and share their own relevant information with the professionals working with them – it would save time and resources for the patient and the professional who will not need to keep asking the same questions and may come up with a shared effective solution. This is currently compounded by the lack of trust between professional agencies and personnel who often misuse or misunderstand what data protection and confidentiality means and use it as means to prevent sharing rather than to finds ways round it. A change in legislation is needed.

    It is also about respecting the ability and knowledge of the patient who is often (especially in the case of long term conditions) the expert in their own care. Mutual respect between the professional and the patient is often the key to success and the frustration for the patient is that they can often identify the best and most cost effective solution but red tape gets in the way. Some of the work on the Common Assessment Framework has identified the common pathways for patients, carers and professionals and also the barriers to working together and achieving the best outcome. This is often related to who holds the purse strings, who controls the information data and in some cases a total lack of respect for the expertise of the patient and carer.

    Patients and carers are good at peer support and there is a need to develop and sustain local and national service user and carer led organisations. They are able to reflect the needs of their members and identify needs and solutions based on experience. This should be outside the competition market so they can represent the needs of the individuals rather than the opinions of the providers of services who have a vested interest in keeping a system that sustains them and therefore have real conflict of interest. For example: where are the patients and carers in the proposals for clinical commissioning? Co-production has become the key word – but most statutory and provider organisations do not understand what it really means and only pay lip service to it. A model of co-production is available which can test how effective an organisation is at doing it.

    Integrated services will only work with patient /service user/carer/ input and needs legislation to remove the barriers to effective and relevant sharing of resources, information and decision making.

    How many patients, service users and carers are involved in the work of the NHS Future’s Forum?

  8. Steve says:

    Good social care is essential to good healthcare and vice versa. Routing Social Care funding through the NHS rather than Local Authority would simplify the co ordination necessary to align secondary care, community care and social care so that the patient journey, admission, discharge, home support etc.. could be managed in a more co ordinated (integrated) way.

    The argument against this is cost, But if its the right thing to do for integration then a way should be found. For example administering social care is proportionately more expensive because of the need to account at transactional level to provide the necessary details to support client billing. A free at the point of need system would dramatically reduce adminstration cost. A halfway house might be to retain residential care in the Local Authority remit, whilst Nursing home care and domicillary care etc.. could be within NHS.

  9. Re Integrated Care

    Changing Faces has been working with children with complex needs and adults with long term health conditions for the last 20 years. All our clients have ‘disfigurements’, conditions that affect their appearance – from congenital, traumatic, dermatological, oncological, neurological or ophthalmological causes. The majority have a combination of physical, functional psychological and social issues.

    Evidence shows that health and social care services currently do not (fully) meet the psychological and social needs of adults and children with disfigurements. This results in a reduced quality of life for many and an increased risk of developing common mental health problems with the likelihood of making further demands on the NHS and social services. We advocate for better quality of life for people with disfigurements through better psychological and social health care.

    Integration of services is crucially important to people with disfigurements and their families as many have mental health as well as physical needs, the latter of which tend to receive more attention. Effective preventive measures can successfully address psycho-social concerns as a result of a facial or body disfigurement; with the right care at the right time, people with disfigurements will be less likely to suffer from depression, anxiety or social isolation.

    Psycho-social needs are best met when addressed in multi-disciplinary care settings where all health and social care professionals take a holistic approach to healthcare. We know of good practice examples in burn care and cleft lip and palate care. In such settings psychologists are included as members of multi-disciplinary teams and bring their broad and specialised understanding of the difficulties of living with disfigurements.

    Multi-disciplinary working, with care pathways that include psycho-social support and interventions, contributes to better joined-up care which we believe should be routine practice in all specialties. However, we know from experience and reports from our clients that services need to be much better integrated in dermatology, ophthalmology, oncology and plastic surgery, among others.

    Barriers to such an integrated approach are often caused by policies and budgets that do not take into account both the mental as well as the physical needs of children and adults with disfiguring conditions. These obstacles need to be tackled and higher priority given to the prevention of mental ill health through integrated services; too often there is a serious lack of resources for preventive services at a local level.

    In our upcoming campaign, we will stress the importance of holistic, patient-centred care for people with facial or body disfigurements – and aim to support professionals and commissioners in improving existing services and designing new integrated services that better meet people’s psycho-social needs.

    In line with our strategy to localise our services and campaigns around Britain, Changing Faces has taken on this week the management from the British Red Cross, at their invitation, of the Skin Camouflage Service which involves 200+ trained volunteers providing advice to 6.500 patients with birthmarks, scars and skin conditions in 150+ NHS settings.

    In the coming months prior to nationwide publicity in January 2012, we will be combining this with our unique psycho-social service led by Changing Faces Practitioners to create a truly comprehensive offer of help – a blueprint for what we think should be available from health and social care services. We will also be making it possible to position Changing Faces Practitioners within multi-disciplinary teams in the future.

    Promoting integrated health care will be one of Changing Faces’ strong strategic foci for the next few years and we would like to offer our experience and expertise to the NHS Future Forum to enable much-needed progress to be made in the integration of disfigurement care services.

    For more information about the charity, see http://www.changingfaces.org.uk and/or contact jamesp@changingfaces.org.uk

  10. Richmond upon Thames LINk overwhelmingly supports the concept and the practice of integrated care pathways across health and social care and makes the following comments:

    Objective must be “timely treatment resulting in best possible outcome / results for patients” and where possible providing and maintaining care as close to home as possible.

    Require a single point of responsibility for the integrated pathway as a whole. This monitoring responsibility should cover flow, quality, timeliness, effectiveness and ease of access / use. “End to End” is the key – the interfaces between the individual parts of the chain of care must be well defined and monitored.

    Health and social care budgets and teams for reablement and immediate care should be merged and therefore commissioned jointly.

    The contracts and contract monitoring must apply to all qualified providers in the integrated pathway i.e. all “joined up”. All providers must be subject to the integration terms and comply with their specific interface requirements and monitoring terms.

    Require a complaints / dispute process for the pathway as a whole as well as the individual component parts. There must be a mechanism for making improvements & enforcing changes where shortcomings are identified.

    Integrated pathways and interfaces must be developed with full involvement of patients and carers, be well tested and understood by NHS staff and PATIENTS.

    The patient should flow through pathway with NO significant wait times between each part of the pathway. The component parts must work together and see themselves as one.

    Patients should have a choice of providers and consultants at each stage within the pathway.

    The pathway / processes within each part of the integration should not be different if used in isolation i.e. do not re-invent wheel and avoid confusing staff & patients.

    There should be easy & fast re-entry points for patients in the event of a re-occurrence of condition.

    Patient details & full treatment history must
    - follow the patient through the pathway fast & seamlessly
    - be available & retrievable within n days as a history after discharge
    - be available & retrievable within n days in the event of further treatment being required
    - be transferable to other pathways / providers within & without area

    Possible Issues ….
    When “payment by results” is initiated, how will this be implemented? For example, will all providers in chain only be paid at end of a patient’s successful sequence of treatment as an incentive to work together effectively?