Developing integrated care: what role do acute hospitals play?

One of the questions I am often asked is: what should the role of acute hospitals be in developing integrated care?

After an informative visit to the Royal Free Hospital, London, last week, I am more confident in suggesting an answer. The hospital’s strategy in recent years has focused on reducing activity and taking out cost in a managed way. This reflects the funding pressures facing the NHS, but also the expectation that the emphasis on integrated care will mean less hospital activity and more care in the community.

The Royal Free has gone about implementing this strategy by appointing its own director of integrated care who has worked with a team of colleagues and clinical leaders to improve care, particularly for older people. Improvements include the introduction of ‘hot clinics’, where older people can be seen urgently without going through A&E, and reducing lengths of stay in hospital through supported early discharge. As a result one ward has closed and the hospital has reinvested the savings in community services.

The focus is now shifting to admission avoidance and the development of community hubs, comprising specialists in the care of older people, GPs and others, to provide multidisciplinary clinics and case management outside the hospital. This includes outreach to residential and nursing homes to prevent avoidable admissions from these facilities. Early experience with one of these hubs is positive, suggesting there is scope to reduce hospital activity further as the momentum behind integrated care in this part of north London gathers pace.

I took three lessons from my visit. The first was the role that providers, including acute providers, can play in developing integrated care. Commissioners are involved in the work I saw but most of the running to date has been made by providers recognising this is the right thing to do, and collaborating with other providers in translating plans into practice.

A second lesson was the strong engagement of clinical leaders, particularly specialists in the care of older people, in improving care. With the support of experienced managers and the use of quality improvement methods, these leaders demonstrated the opportunity to improve outcomes and cut costs, echoing the message from Brent James of Intermountain Healthcare at the Fund’s annual conference in November.

A third lesson was that this is hard work and it takes time to deliver results. I was told that a realistic timeframe for making substantial improvements across the hospital and the local system of care was years rather than months. This echoes experience outside the NHS where quality and service improvement are quite rightly likened to a marathon and not a sprint.

One other insight from my visit was the success of the Royal Free in delivering the four-hour A&E target, in part by hiring GPs to assess and treat walk-in patients in the hospital’s urgent care centre located next to A&E. Around 50 local GPs work in the centre and they are seen as an essential resource in enabling the four-hour target to be achieved on a consistent basis. Closer integration between GPs and hospital clinicians is another part of the answer to improving care.

This blog is also featured on the Health Service Journal website.