Integrated care: a story of hard won success
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3529 (Published 31 May 2012) Cite this as: BMJ 2012;344:e3529
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In response to Richard Vize's response to my posting:
Richard does not seem to have addressed my main point which is the lack of balance in the article, and the subsequent presentation of a rather one sidely positive overview. Given the resources going into this pilot at a time of severe financial restriction, this lack of balance is not something to be shrugged off, in my opinion.
Richard says my last paragraph is untrue. Which bit? It does say on his website that he "wrote a marketing publication for a major consultancy" - see the section "Personal profile/ 2011 to present as Public Policy Media Limited". McKinseys are such an organisation, and since they have been running the ICP(a fact which is glaringly absent from his article), I simply expressed the hope that Richard had not omitted to mention any connection he has with them, as that would clearly constitute a potential conflict of interest. I would be very reassured to hear that there has in fact not been any connection, although given both Richard's and McKinsey's high level involvement at senior health policy level over recent years, it is hard to believe that there has not been at least a degree of informal contact.
This notwithstanding, I made no untrue statement in the last paragraph, and I do not feel it is fair of Richard to say that I did.
There are a number of other problems with the ICP that I did not go into, which I would be very happy to discuss with Richard, or anyone else that is interested, since I am certain we are both motivated by the same desire to see good and innovative health care provision utilising resources maximally and equitably.
Competing interests: No competing interests
The article illustrated the complexities of establishing integrated care schemes, focussing on the fact that successful integration in health and social care is ultimately dependent on overcoming professional boundaries and developing strong relationships among clinicians, managers and others rather than on technology. It also emphasised the high cost and legal and financial difficulties which stand in the way of providing patients with the integrated service they deserve. The article and the wider issues it raised were discussed at length at the health select committee on 26 June.
The data quoted on clinical outcomes is the best available.
Your final paragraph is simply untrue.
Competing interests: No competing interests
It was a somewhat surreal experience reading this article as the realisation dawned that it was describing the same Integrated Care Project that my practice has been engaged with.
The numbers for reduction in admissions should not be so baldly claimed to be due to the ICP since (1) it has not neen running long enough (2) the target provider of inpatient services was actually closed to admissions for substantial periods and (3) the ICP is by no means the only area where we and other practices are active doing work on reducing admissions.
The clinical meetings are time consuming and in our experience of only limited benefit. The care planning tool, when it works at all, we find to be almost completely unhelpful.
No mention is made of the very expensive involvement of the Management Consultancy firm of McKinsey. Although we cannot get accurate figures (so called commercial confidentiality) it is rumoured this has cost the NHS seven million pounds so far.
While clearly some practices are impressed with the project, we know that ours is by no means the only one that is not, and the article suffers from a complete lack of balance in that regard - but then it seems it was not peer reviewed, an odd situation for such a high profile article in a prestigious journal.
In fact, given that the project is currently up for review, the timing and lack of balance in the article make it seem little more than a piece of propaganda. I note a survey of patients engaged in the project that was published a few months ago was highly uncomplimentary - something the author neglects to make any mention of.
Overall this one sided presentation does no credit to the editorial integrity of the BMJ.
I note the author states that on his website he has done work for management consultancies working in the public sector. McKinsey's is one of the most active of these - I do sincerely hope the author has not neglected to flag any such connection up in the declaration of interests section.
Competing interests: No competing interests
In Richard Vize's article on a successful Integrated Care programme, it is refreshing to read of the strong emphasis on time spent together to build and maintain professional relationships, in addition to the more 'mechanical' processes such as aligned financial incentives and sophisticated IT … "by the second or third time you meet you start to relate to people, break down barriers, and find common interests".
At the same time as the North West London pilot for diabetes and elderly care, another group of North West London clinicians have been piloting an integrated care pilot in child health: growing the experience 'bottom up' to make it work. Mr Vise writes that "what fires up doctors is the chance to exchange ideas on care with other clinicians", and exactly for that reason, we created outreach paediatric clinics in GP practices combined with a multidisciplinary team meeting, with trainees playing a key role. These have cost almost nothing and our evaluation (a qualitative thematic analysis) has demonstrated how well the pilot creates trust, builds relationships, develops strong communication channels and generates a culture of learning for GPs and paediatricians alike –qualities that Mr Vize emphasised in his article.
We believe it is crucial to provide opportunities for general and specialist trainees to work in these integrated care settings, if the benefits of these new ways of working are to become mainstream.
Competing interests: No competing interests
Dr Elizabeth Paice and her team are to be congratulated for setting up integrated care for patients with diabetes and those over 75 years in these turbulent times. The paediatric unit at Northwick Park Hospital was opened in 1971 and by 1977 we were providing an integrated service for the 60,000 children of Harrow(1). Subsequently, our annual reports showed that a wider more appropriate spectrum of services were being provided, the length of stay was reduced and the number of admissions fell(2).
In the mid 1990s disintegration began with the withdrawal of the paediatric social work support to a central office and a few years later the child and adolescent psychiatric services moved to a site at the other end of the borough. The close daily contact between essential professionals for planning and implementing effective and efficient patient care was lost.
Dr Elizabeth Paice achieved integrated care, but how will she prevent disintegration?
(1) Valman HB, Liberman MM,. Snow P, Wilson J,Samuel OW, and Lindsay-German J. Child Health in integrated Child Health Service. Health Trends 1977: 9, 30-33
(2) Valman HB. Working for Children: development of the Paediatric Unit at Northwick Park. London: Harris, 2006
Competing interests: No competing interests
Re: Integrated care: a story of hard won success
As the commissioning editor of this feature I am happy to clear up any remaining doubts in Matthew Johnson's mind as to Richard Vize's competing interests in this case. As suggested by the competing interest statement posted by Vize at the foot of this feature, he has never carried out any work for McKinsey and Company.
Competing interests: No competing interests