Executive Summary:
At its most basic, integration consists of coordinated care across different services and levels of care. It aims to place patients central to the design and delivery of care and meet their needs through apparently seamless, high quality and effective services.
The Royal College of General Practitioners (RCGP) has been a champion of integrated care systems throughout its history. More recently the College has developed the concept of Primary Care Federations and worked with other Royal Colleges to develop models for integrating care across health services.
There are already numerous examples in the UK and internationally of how integrated care services can be developed. Some of the benefits demonstrated include better patient experience and satisfaction with services, improved clinical outcomes, and cost efficiencies.
These examples also highlight that there is no one definition of integration, and that integration of care can take many forms. There are also challenges to implementing integrative approaches to improve care.
The RCGP wishes to consult on what integration means for general practice and general practitioners (GPs) in order to develop a policy that can guide decision making and service design. It has produced a consultation paper which has raised a number of issues for general practice and these issues are summarised below. In order to gather views on integration, RCGP has posed a number of questions. The College will also use the consultation feedback to respond to the Department of Health established Future Forum, which is gathering views on integration to provide further advice to the Department.
Issues for general practice:
1. In order to implement integration in general practice a shared understanding and definition is essential.
2. Integrated care requires seamless transfer of patients and individuals across a number of services. How this can be realised alongside competition and choice of provider needs to be explored.
3. GPs are increasingly becoming involved in commissioning decisions which includes the commissioning of integrated care services.
4. The role of commissioners to ensure that the needs of their population are met means that commissioners need to be making the decisions as to what integrated services are required and where. However in areas where there are few providers or where providers have a monopoly, the providers may be able to bring undue influence as to what services are commissioned.
5. A system which incentives providers to increase activity and use the most costly interventions to increase income is contrary to the role of primary care to reduce the need for secondary care, manage budgets, prevent and treat conditions early, and provide services closer to home.
6. With the abolishment of Primary Care Trusts, leadership and management capacity will need to be developed in other parts of the healthcare system to lead on and facilitate joint working and the integration of care services.
7. General practice may need to draw on specialist advice from providers and other health care professionals to provide effective integrated services, and the healthcare system needs to be able to support the sharing of expertise.
8. If practice boundaries are abolished, as suggested by the Government, the geographic spread of patients and their need to access services remote from the GP could pose challenges to providing integrated services.
9. Joined up information systems and shared care records will facilitate the sharing of information and joint working but requires investment and sufficient data protection safeguards.
10. Performance and outcome measures should be aligned across different care services to support, rather than hinder, the setting of shared goals. There are still few NHS outcome measures available for monitoring the effectiveness of services.
11. Reducing health inequalities and improving equity of care in the new system is a guiding principle in the NHS. However the determinants of health inequalities are often outside the scope of health services.
12. It is essential that integration does not lead to new barriers between services, such as condition specific services, and silos of care provision.
Comments on Royal College of General Practitioners
Integration of Care Consultation
The Royal College of Physicians of Edinburgh (the College) welcomes the opportunity to respond to the RCGP Integration of Care Consultation.
The College has the following answers and comments on the specific consultation questions:
1. What in your view are the three main benefits of integrated care? (p. 3)
- The College considers that one of the key benefits of integrated care is that the individual patient will be put at the centre of the healthcare system rather than their diagnosis or disease. For example, a patient may present with several different health problems and integrated care should mean that they receive a much more holistic approach to their care, in theory helping to address points such as support and care required after an operation at an early point in the patient journey, therefore improving the patient experience.
- Another benefit of integration will be faster resolution of problems, and faster diagnosis and treatment. This should be more cost effective than the current system in the long term, as problems are identified earlier and can be managed from the outset. Patients should not be sent inappropriately to multiple secondary care clinics or accident units for "rule out" attendances as more effective triage will take place.
- Integration provides a good opportunity for effective discharge planning as, for example, there will no longer be artificial boundaries between health and social care and their relevant budgets.
2. What are the risks of integrated care? (p. 3)
- The risks of integrated care include a reduced standard of care if provided by less well trained or experienced staff than currently provide the service. There is a danger that a one size fits all approach could be adopted which does not work for individuals.
- There is some concern that integration could lead to poor clinical governance and lack of clinical responsibility. There is not always effective communication in the NHS between departments and between primary and secondary care. Integration means this would have to be much better - can that be delivered?
- There is a possibility of conflict of interest for GPs and other health professionals where a financial incentive exists to provide a service in the integrated system, and the necessary checks and reviews to ensure that commissioning is appropriate could be prohibitive. The reconciliation of competition and choice with integrating services could be challenging, particularly in more remote and rural areas where little choice exists.
3. What definition of integrated care do you believe should be used to inform policy decisions? (p. 1)
The College feels that the definition of integrated care must be broad and incorporate both horizontal and vertical integration. The definitions listed in the accompanying Consultation Paper by the WHO 1 and Nuffield Trust2 provide a sound basis to inform policy decisions.
4. How can competition and choice of provider be reconciled with integrated care services? (p. 4)
This has the potential to be challenging as each clinical scenario has different demands and requirements which may or may not be compatible with the idea of increased competition for services. Improved patient outcomes must at all times drive these proposals.
There will be increased pressure to manage budgets transparently as those acting as integration coordinators may also be acting as providers of services, and therefore again the interests of the patient must always be at the fore.
5. Who should make decisions about what integrated care services are required in a given area? (p. 5)
Decisions need to be driven by local needs. A form of partnership committee should be created in each given area, including experts from primary and secondary care and other professions.
6. What role should providers take in developing integrated care services? (p. 6)
Providers should take an open and active role.
7. How can models of payments be reformed to support integrated care? (p. 6)
One possibility is a single payment to the commissioned integrated provider network which is used to subcontract required services. However, the payment would need to reflect local value and local population outcomes and needs.
8. What leadership and management skills are required to develop integrated care services? (p. 7)
Initially this requires high level involvement of commissioners and Trust boards, including medical director or clinical service lead level.
9. What are the risks and opportunities of involving nurses, specialists and Allied Health Professionals from providers in the commissioning of integrated care? (p. 7)
There are potential problems for integration when there are different providers of the different components, for example, GPs versus hospital based organisations, both with their own budget pressures.
There will, however, be opportunities to ensure that the latest and most useful interventions are supported by the commissioners.
10. What impact will the abolition of GP practice boundaries have on the commissioning and provision of integrated care? How might these problems be resolved? (p. 8)
No comment.
11. What do you need from information systems to support integrated care, and how should they be funded? (p. 9)
The College feels there is a clear need to improve information systems across the NHS, and particularly to progress the use of electronic records. Information should be able to be shared with all providers in primary, secondary and community care where appropriate with all the usual security safeguards.
Use of electronic records and improved information systems will develop at different rates across the country, and funding needs to be locally adapted to recognise local circumstances. It is unlikely this will be funded at a national level in the short term following the report in August 2011 of the Commons Public Accounts Committee on the National Programme for IT in the NHS.
12. How might outcomes measures be used to support integrated care? (p. 11)
There is a need to identify clear, measurable service quality indicators, which should reflect the journey of care as well as clinical outcomes.
It is important to use indicators such as improved well-being, reduced hospitalisation, improvements in independent living and local healthy longevity figures to measure and assess the success of integrated care.
13. How can integrated care help to reduce health inequalities? (p. 11)
In theory, integration of care should help to address health inequalities. However there is a risk that postcode inequalities may be exacerbated dependent on local service configuration, as some areas may be much better served than others.
14. How can integrated care services prevent silo working? (p 12)
Silo working may be avoided by encouraging the involvement of generalists and/or by auditing outcomes. Clinical governance is essential to identify deficiencies in the service.
15. Are there any other important issues not identified above?
No. The College’s main concerns are over the clinical governance of integrated care and that the development of services is for financial rather than clinical reasons.
16. How can the RCGP help to ensure that integrated care services are developed in the future?
The development of integrated care services requires close working between the RCGP and the other medical Colleges, as well as relevant bodies and organisations with an interest.
1 http://www.rcgp.org.uk/policy/rcgp-policy-areas/integration-of-care.aspx, p1
WHOsuggests that integrated care is ‘the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.’
2 Ibid, p2
The Nuffield Trustdescribed the term as reflecting ‘a concern to improve patient experience and achieve greater efficiency and value from health delivery systems. The aim is to address fragmentation in patient services, and enable better coordinated and more continuous care, frequently for an ageing population which has increasing incidence of chronic disease.’