Integration has got a few mentions in the Health and Social Care Bill: commissioners and regulators have new duties on joining up care. That's all sorted then, right?
Well, it is a good start, although there is still a lack of consensus on what should actually constitute integrated care and how to make it happen. To offer a way forward, the charity coalition, National Voices, has been working with its members – 130 health and social care charities - to develop the Principles of Integrated Care.
Patients' point of view
Based on the experiences of service users and on research evidence, the 12 Principles give guidance to government, commissioners and health professionals and describe what joined-up care might feel like from the patient’s point of view.
At their briefest the Principles outline that, to work in the interests of patients, carers, service users and their families, integrated care must:
- Be organised around the needs of individuals (be person-centred).
- Include community and voluntary sector contributions.
- Focus always on the goal of benefiting service users.
- Be evaluated by its outcomes, especially those which service users themselves report.
- Be fully inclusive of all communities in the locality.
- Be designed together with the users of services and their carers.
- Deliver a new deal for people with long term conditions.
- Respond to carers as well as the people they are caring for.
- Be driven forwards by the commissioners.
- Be encouraged through incentives.
- Aim to achieve public and social value, not just to save money.
- Last over time and be allowed to experiment.
GPs will of course be at the very heart of the integration revolution both as general practitioners and as commissioners. So, what are the key challenges as National Voices sees them?
The overall responsibility of GPs in joining up care for their patients was set out unequivocally by Dr Clare Gerada, chairwoman of the RCGP. However, the role of the GP in multi-disciplinary teams is one to explore. These teams do not have to be in one organisation – they can exist across health, social care and voluntary sector provision.
For example, the role of key contact can be delegated to other staff such as the specialist nurses – either in hospital or the community – whose role is highly valued by people with diabetes, Alzheimer’s and musculoskeletal conditions.
Carers are, in practice, often the people struggling to join up care for the patient. Both as providers and commissioners, GPs need to work as partners to carers as much as to patients. Barriers to carer involvement in decisions must be removed.
National Voices has called for a 'new deal' for people with long-term conditions and here integration is key. As well as a designated care coordinator and support to navigate the system, this involves patient access to records; a jointly prepared care plan; and support for self-management. The evidence shows these factors improve not only care but also the use of resources.
Including the voluntary sector
GPs, as commissioners, will be improving engagement not only with individuals, but also the voluntary sector and the wider community. There are particular challenges in engaging with and meeting the needs of people with the most complex health needs and people from minority and socially-excluded groups.
Charities and community groups will be able play a role here, for example in helping to identify gaps in provision and discontinuity. They – we – aren’t there simply to point out issues but can also offer expertise and, in many cases, solutions. We believe the voluntary sector should be seen as the ‘third circle’ in the Venn diagram of integrated services, overlapping with healthcare and social care.
Innovation will be a major factor in joining up care. We need new approaches and integration pioneers need support, incentives and room to experiment. There is particular need for fresh thinking over multiple settings - when the Nuffield Trust searched for innovative examples of integrated care, they found that most recent examples had been initiated by providers. A range of different approaches over multiple settings should be developed and tested and we need to see commissioners taking a lead in this.
Example taken from National Voices website: Malcolm Pointon's 'web of care' - Alzheimer's Disease (Alzheimer's Society)
Similarly we need new approaches to the evaluation of integrated care. While existing mechanisms like Patient Reported Outcome Measures (PROMs) should play a key role, most current approaches tend to focus on treatment in relation to single episodes of care, usually in specific care settings, such as a consultation with a GP or following a surgical treatment in hospital.
Again, GPs, as commissioners, will need support. The DoH is quietly exploring new approaches but National Voices is calling for bigger and more urgent priority investment in the development of outcome measures for people going on ‘care journeys’ across and between services, and over time.
This is a brief taster and we urge you to read the full National Voices Principles of Integrated Care document. We hope GPs will see this as a platform for further discussion with voluntary organisations. Meanwhile, we know lack of joined up care remains the biggest frustration for patients, carers and other service users.
And we know that sorting it out will make a vast contribution both to the safety and quality of care. If you should need any further convincing, have a look at the care webs service users have drawn up to demonstrate the complexity they have to navigate at the most stressful times of their lives.
We have been talking about integration for years. Now let’s make it happen.
- National Voices is the coalition of health and social care charities working to strengthen the voice of patients.
- Jules Acton is engagement director and Don Redding policy director at National Voices