Archive | April, 2015

The challenges of integrated care

16 Apr

by Jonathan Stokes, PhD student in Multimorbidity theme

JStokes_April15blog_poster pic

At the end of last month I was back in my undergrad University town of Edinburgh, for the ‘15th International Conference on Integrated Care’.

All in all, it was a really interesting conference. I did, however, come across some frustrations, and they in fact reflect some of my frustrations with the topic area of ‘integrated care’ as a whole…

First of all, the question, ‘what is integrated care?’ is very much glossed over. It’s far from a clear concept, but instead of addressing this issue properly, the majority seem to push ahead with an outcome-oriented definition (e.g. ‘integrated care’ is the production of the ‘feeling of integration’ in the end user – the use of which I question to local policy-makers trying to put this into practice), and a ‘bottom-up’ approach (i.e. letting local areas come up with their own examples of ‘integrating care’).

While ‘bottom-up’, or ‘grassroots’ approaches are beautiful buzz-words, it’s hard to see how these highly-localised approaches, frequently small projects, and disease-focused (ironically, given that ‘integrated care’ is partly in response to the growing number of people with multimorbidity – many conditions – for whom the disease-specific systems we already have cause added problems and safety concerns) can result in anything but a highly fragmented ‘integrated care’ approach, at least without the proper top-down oversight and co-ordination.

The apparent results of this approach, at least the majority in the NHS context, is an over-reliance on ‘case management’ – identifying a small proportion of the population at ‘high-risk’ and assigning a team/individual to look after their care co-ordination – as the embodiment of integrated care. This approach fits clearly with the outcome-oriented definition, but evidence for its effectiveness beyond an extremely small increase in patient satisfaction is lacking (I have a systematic review on the way in due course), and only a tiny proportion of the population even potentially benefit.

For true population-level effects, and the system-wide changes clearly needed, we need to embrace a systems-approach to integrated care, in my opinion. This was the subject of the poster I presented (see below), which shows the framework of a health system (white boxes) and outlines some practical examples of ‘integrated care’ that can occur at each level (grey boxes).

Through the ‘systems lens’, integrated care can be thought of as any improvement to the ‘interconnections’ between elements or levels of the system. Interconnections in a system can be physical, but more frequently are information flows, perhaps explaining the difficulty researchers have had in pinning down the concept. For this reason, integration occurring at the ‘foundation level’ of the system (financing, governance & organisation, resource management) is vital. Practical things like linked IT systems between your GP, hospitals, social care etc. Most people I explain about the lack of this connection in the majority of the NHS (with the notable exception of Salford more recently), can’t believe the lack of this linkage! That you could be admitted to hospital, and that they have no idea of your previous medical history/allergies etc., all contained on your GP record, is really outrageous in our information age.

These, though, are the kind of changes that are extremely difficult to make at a local level, from the ‘bottom-up’. They require investment, co-ordination, and usually legislation to implement. They also occur further away from the patient interaction than service delivery interventions, so don’t fit quite as neatly with the outcome-oriented definition. Additionally, the NHS has had past failures in implementing, for instance, a unified IT system nationally, despite investing billions of pounds in the attempt.

I must say, it was refreshing at the end to hear from the Scottish government who spoke about “allowing the ‘bottom-up’ innovation using the heavy hammer of top-down legislation”, having just launched an extremely comprehensive integrated care plan.

Perhaps, then, devolution may play a part in being better able to implement these system changes, perhaps we’ll see in Greater Manchester from April 2016

“Why do they do this to me?” – The inner cry of a child whose two crimes were to be gentle and poorly

1 Apr

by Max Scott

  • Part 2 of blog series “The desperate fight to be heard, and supported, when living with the invisible struggles of Multimorbidity”
  • Introduction to blog series available here
It would not be what he hoped it would be

It would not be what he hoped it would be

Mums eyes misted over as she watched the pale, frail looking boy set off to the neighbours a few doors away for his lift to school. Thin, white, bony legs exposed to the winter cold from below his short uniform trousers, he was not really strong enough to return to school, and my mother was fully aware of this. But what could she do? Her son had missed so much education. That boy, of course, was me.

Once at school, I spent my time in the classroom struggling to catch up with the work missed in my absence, and my time in the playground struggling to deal with the pain and misery of being punched and kicked by the other kids who found me an easy target, with my weak limbs and gentle disposition.

As a severely asthmatic child from around the age of one, I never knew what it was like to be well, or to have any continuity with schooling or building friendships. I was unable to develop the social or survival skills that could have made this early period of my life that little bit easier.

So this, in a way, could have been useful preparation for having to deal with the challenges that face me now. Except that now, those challenges are rather different. Back then, I just wanted to be left alone by those who made my life more difficult. Now, I just want to be listened to by those who could make my life that bit easier. I was unable to achieve the former. Now, as an adult, armed with more experience and the ability to string a few words together, I strive to achieve the latter.

My future posts will try to give an insight into the gradual and shocking realisation that my health issues were multiplying, to the extent that they were taking over my life, that they were mostly invisible to the outside world, and that, remarkably, on top of my having to come to terms with this…my doctors seemed to be responding with scepticism.