Clinically integrated systems: the future of NHS reform in England?
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d905 (Published 28 March 2011) Cite this as: BMJ 2011;342:d905
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Rapid response to: "Clinically integrated systems: the future of NHS
reform in England?
Parallels with integrated patient pathways?
We agree with Ham and colleagues that integration of clinical care
systems is difficult to achieve because it means close collaboration
between professionals and their respective organizations (and possibly
policy makers) to overcome fragmentation of services1. It follows that an
integrated care system needs an integrated approach to consider all steps
necessary for successful implementation. At this point we want to
investigate parallels between integrated care defined as large
collaborations between health and social care, and integrated care along
the patient pathway. An example is the pathway of patients suffering from
acute stroke.
Patient pathways, such as the acute stroke pathway, are often constructed
as a (complex) multifaceted chain of links from symptom onset all the way
to treatment in the hospital. Acute stroke is the number one cause of long
-term disability around the world. Currently, acute stroke treatment, i.e.
thrombolytic therapy, suffers from substantial undertreatment of eligible
patients. As with integrated care, slow progress of implementation of
services is signaled. This is corroborated by Addo et al, who recently
described the very slow introduction of adequate and integrated acute
stroke care even in South London2. Classical methodologies to improve
practice still rely on costly and time-consuming 'trial-and-error'
experiments. These scientific studies typically focus on a single link in
the patient pathway causing fragmentation of results and lacking an
integrative approach. An integrative approach, as with integrated clinical
care systems, should consist of the planned coordination of all
stakeholders along the patient pathway from the beginning to the end.
To facilitate and promote an integrative approach, industrial engineering
methods, such as simulation based approaches may be used in addition to
classical experimentation to investigate all activities along the pathway.
For example, a discrete-event simulation model was used to investigate a
comprehensive care model from symptom onset to treatment in the hospital,
and found that a guideline compliant treatment strategy resulted in an
increase of treatments for patients suffering from acute stroke3.
Considering all parties in a model for integrative care has several
advantages: it enables investigating the overall patient pathway and
identifying specific barriers and bottlenecks for implementation. Moreover
possible interactions between the individual links in the chain may be
assessed.
An integrative approach departing from patient level is mandatory to
advocate the development of future care models that meet the demands of an
ageing population. We believe that in order to improve implementation of
health services, we need to design and optimize comprehensive care models
with close collaboration between clinicians, policy makers, and most
importantly, the patients. Efforts involved in such model development
force a rethinking of current methodology and tools.
Competing interests: None declared
Reference List
(1) Ham C, Dixon J, Chantler C. Clinically integrated systems: the
future of NHS reform in England? BMJ 2011;342:d905.
(2) Addo J, Bhalla A, Crichton S, Rudd AG, McKevitt C, Wolfe CD.
Provision of acute stroke care and associated factors in a multiethnic
population: prospective study with the South London Stroke Register. BMJ
2011;342:d744.
(3) Stahl JE, Furie KL, Gleason S, Gazelle GS. Stroke: Effect of
implementing an evaluation and treatment protocol compliant with NINDS
recommendations. Radiology 2003 September;228(3):659-68.
Competing interests: No competing interests
Ham and colleagues (1) have provided a much needed article on various
forms of clinical integration in community care for vulnerable older
people and patients with chronic disease. This contrasts with usual
evidence free diatribes about the need for more competition in the 'health
economy',dividing purchasers (often primary care) and providers(secondary
care).
I would like to add 3 other points to this discussion based on our
experience of informal integration between primary, secondary and social
services clinicians in Whitby - a small town in North Yorkshire surrounded
by the North York Moors.
1. We have had to integrate our expertise because of long standing
insufficient funding. Therefore, being resource poor can sometimes be
useful because it genarates innovation in order to survive. Recent
interest shown by a number of mental health services from London
concerning our practice of working together, reflects their current
resource and overhead pressures.
2.The main practical objective of integrated care is to set up care
pathways for major disease groups such as cancer and dementia. Integration
of whatever type results in pre ordained pathways, with a variable
evidence base, often applied to populations dissimilar to those studied.
The rigidity of these pathways make them difficult to 'escape' from - for
both patients and clinicians. The alternative approach would be through
patient held budgets (invoving a health and social care charge card) where
care pathways would be organically forged by frequent use. This process
also permits 'escape' when changes of diagnosis and client characteristics
necessitate this.
3. In Whitby we have used informal integration for patients,carers
and professionals to learn from each other; a 'learning network'(2).
Working together and subsequently reflecting on real life episodes of care
have helped to increase our collective competency, and promoted smarter
ways of intervention (often earlier than conventionally stipulated).
I hope that our political masters think again about market reform and
carefully use available national and international evidence when deciding
on the future of community care for vulnerable people reflecting the views
and experience of carers and clinicians.
1. Ham, C., Dixon, J. and Chantler,C. Clinical;ly integrated systems:
the future of NHS reform in England? BMJ 2011; 342:740-742
2. de Silva, P.N. New ways of working with primary care; proactive CMHT or
Polyclinic? Progress in Neurology and Psychiatry, Vol 13, issue 1, june
2009
Competing interests: No competing interests
It proves very difficult to straddle community-based care with
hospital care but clinically integrated systems lie at core of an improved
patient journey. An ageing population and the extra requirement for more
comprehensive, anticipatory discharge arrangements requires engagement
with families/carers. Often we lack conviction in asking families to take
on additional care needs that simply cannot be met by social care. Even
if there is an integrated service, we have to ensure that patient wishes
are integral rather than subsumed by trust wishes on performance.
Competing interests: No competing interests
Chris Ham and colleagues are partly right that there is no inherent
contradiction between pursuing competition and integration simultaneously
and I agree with their concluding remark about focus on medical groups of
GPs and specialists. (1). Indeed we could look to the airline industry to
give us a clue on how this could be achieved. There is considerable choice
and competition between different airlines, each of which manages the full
end to end process from ticket booking, check in to safe disembarkation.
Medical Groups around clinical specialties could be like the airlines with
GPs and hospital clinicians working together to develop and deliver the
full pathway, and hospitals providing the necessary infrastructure just as
airports do by providing buildings/waiting areas/security/baggage handling
etc. But I do not believe that this either ensures comprehensive coverage
or is feasible given the way the NHS is organised at present.
The difficulty with the current debate is that we are stuck in the
paradigm of commissioning/competition/choice, and are trying to find
reasons and workarounds to justify this. We keep pursuing the panacea of
purchasing and markets and which has failed since its introduction in
Working for Patients by the Thatcher Government. I do not see how the much
needed integrated model demonstrated by Torbay or the Veterans Health
Administration can be built on the general practice commissioning
platform. Yes, commissioning may make some difference in a small
proportion of the comprehensive health care needed by the population and
yes, it could work in some geographical areas but will it work for all
services and in all places? I doubt it, and hence any small gains from
commissioning have to give way to the bigger needs of integration. Time to
stop justifying commissioning and time to adopt integration as the new
single organising principle for the NHS?
The views expressed are personal.
1. Ham C, Dixon J, Chantler C. Clinically integrated systems: the
future of NHS reform in England. BMJ 2011; 342: d905
Competing interests: No competing interests
Alice in NHSland
No doubt the development of integration is better than unintegrated
care.
US reforms happened a decade ago; I have a book on integrated
delivery systems from the 1990s, and the much praised Kaisers and Mayos
have their origins many many years ago. All this is so much history.
Surveying commissioning bodies, health professionals is also well and
good but these groups remain trapped in the current paradigm of
powerlessness otherwise they would have done something. I make the simple
point that if these bodies thought integrated care were such a good idea
why is it proving so hard to achieve?
The former CEO of Kaiser made a point, gosh 10 years ago perhaps,
that only the patient has the experience of the extent to which care is
integrated. Providers and purchasers (whatever the politically correct
term is these days) can only fantasise about integration as they move
their little pieces around, thinking that integration is achieved through
some organisational alchemy.
The NHS has its strengths, but one weakness is that because patients
are insulated from costs, they are similarly insulated from the decision-
making about their care. And their choices have little real impact on the
NHS -- I can't take my money elsewhere as the NHS is a monopoly consumer
of taxpayers money.
John Hammergren of McKesson says patients need to have some 'skin in
the game'. In Germany, Spain and a host of other countries including a
favourite of mine, the Netherlands, patients do have some skin in the
game. Much of US responsiveness lies in this reality, which does not exist
for the NHS. These other systems are far more responsive to patient
preferences, despite the research on the social inequality of copayments -
- but what is the greater evil, some social inequality, or massive
misspending of taxpayers' money?
Until user interests can express themselves powerfully and I don't
mean through consultation, the interests of purchasers and providers will
dominate. We know that provider capture means supplier interests dominate.
Purchaser interests are focused on provider configuration as a proxy of
user needs and hence of the form that integration of care will take.
And so it comes back to the question, if integration is such a good
idea, what is stopping people? Perhaps the purchasers and providers are a
bit like Alice, running very hard simply to stay in the same place.
Competing interests: No competing interests