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

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