Clinically integrated systems: the future of NHS reform in England?

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.