Building the narrative for integrated care

At the beginning of last year, The King’s Fund and the Nuffield Trust published an influential 10-point plan on Integrated care for patients and populations, to support the Department of Health and the NHS Future Forum’s emerging strategy on integrated care. We argued that the first task was to provide a compelling narrative for integrated care: to define its ambitions and set out what it would look like in practice, backed up by specific and measurable objectives to drive quality improvements.

Over the past year, the government has certainly embraced this: the duty to ‘co-ordinate’ care is in the NHS mandate and is a responsibility of the NHS Commissioning Board; Monitor is tasked with promoting integrated care; and Norman Lamb recently announced new waves of ‘at-scale’ integrated care ‘experiments’. Many clinical commissioning groups and local authorities have put integrated care at the top of their commissioning agendas, and the energy to drive forward partnership working locally is tangible.

But what of the supporting narrative for integrated care? Building a narrative around the users’ perspective – for example, through improving care for Mrs Smith in Torbay – makes good sense as this aspect often gets lost in the process of ‘doing’ integration. Last year, National Voices was commissioned by the NHS Commissioning Board to create a narrative for person-centred co-ordinated care at a national level, centred on the needs of patients, carers and other service users. This work is currently out for consultation.

National Voices have created a set of ‘I’ statements that set out what service users should expect in terms of: goals/outcomes; communication; information; decision-making; care planning; transitions between service settings; and emergencies. The common vision for integrated care from the service user’s perspective is described as 'my care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes’.

National Voices’ narrative is a helpful first step in providing local health and social care system leaders with a set of principles for ‘what good looks like’. The narrative invites these organisations to develop their own ‘we’ statements on what they would do to meet these ambitions. A national policy framework on integrated care, written jointly by the NHS Commissioning Board, Monitor, the Care Quality Commission, the Local Government Association and Public Health England, is likely to articulate this at the system level.

That the Board wishes to build the vision for integrated care from the user’s perspective is heartening, and the work of National Voices provides the first step in meeting the twin challenges that we set out for the narrative last year: it fully defines both the ambitions for integrated care, and what it would look like in practice. However, there is a danger that the principles for integrated care through the ‘I’ statements may fall firmly into the ‘motherhood and apple pie’ category – ie, empty rhetoric – unless they are used to drive service improvements locally. Specific goals and measurable objectives are required in order to focus and prioritise activities, particularly those related to the service users’ experiences and needs.

Moreover, the hypothesis of integrated care is that it should improve not just the user experience but also care outcomes – for example, improving people’s management of their chronic illnesses, promoting better quality of life, enabling independent living at home, or reducing unnecessary visits and lengths of stay in hospitals.

An overarching narrative, while rightly driven from the needs of service users, must recognise that the purpose of integrated care is to bring commissioners and providers together to co-ordinate care better. It requires an articulation of the commitments that are needed to make this work, at every level from policy-makers through to teams providing frontline care. No two approaches to integrated care will look the same in practice, but the principle involved in breaking down organisational and professional barriers and building up new alliances and partnerships will be the same. The end result should be a system that can demonstrate improvements in both people’s experiences and care outcomes over time, particularly to the most vulnerable people in our communities who are currently so ill-served by fragmented care.

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