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.
Chris
At the risk of being considered controversial, I think the whole Transforming Community Services Policy has a lot to answer for. Acute secondary care providers spend a lot of time doing post acute rehab for people recovering from acute illness or injury and a lot of time trying to turn people around and back home from the front door of the hospital. Yet contracts for community service provision have often gone to social enterprises, private sector companies or mental health trusts, none of whom have any form in this area. Why? Because of ingrained hostility to the big bad acutes who were somehow going to asset-strip community services. Yet when we look at "vertically integrated" providers, they have staff working across acute and community, they have the capacity to close capacity in the acute and transfer it to services outside hospital, they can abolish "death by assessment/multiple referral". If you look at some of the transformative work on "discharge to assess" or early supported discharge or community geriatrics, one organisation running acute and community services has proved a boon. Pragmatism over ideology and tribalism
Chris. As the Community provider who work with the RFH really closely on integration I can agree with much of what you have said. They are great partners to work with. I am taken aback however that the considerable leadership and involvement of my community services and the really innovative work we do on a daily basis doesn't seem to feature at all! I also have to say that the CCG Chair and their Board and all of our GP colleagues in Camden have been pivotal in driving change. Please don't be blind to my staff's incredible contribution. Come and see us!
Best wishes
Claire
I once heard someone challenged about their religion. To which they replied `I don't have to prove it, I believe it'. I feel the same about the need for integrated care although, given the will of all providers, there are human and financial facts to support it. Without a move - and soon - from the hospital to the community for at least one in four patients filling acute beds, proper, safe, care for the individual and the state funds to pay for it will both be totally inadequate. Listen to the patients. That's what they want. And I know that's what they need.
Chris, as the Chief Officer of Camden Clinical Commissioning Group I am of course delighted with the way the Royal Free is working to continuously improve the experience and outcomes they deliver for their patients. I would endorse Claire's comments however that it would have been much harder without the active involvement and excellent leadership of the community services in Camden delivered by CNWL, as well as primary care, social care and commissioners. Integrating the whole system around specific population groups requires all those involved to work collaboratively, and that is what we are doing in Camden.
Come and see us too!
David
I am aware that Claire, David and colleagues have been valued partners in the work I described in my blog. The reason I wrote it from the perspective of The Royal Free is that in my experience it is relatively unusual for an acute hoospital to be so involved in the development of integrated care. I will be taking Claire and David up on their kind invitations to visit - and fully expect an avalanche of emails from acute trusts elsewhere in the NHS who are also doing good work on integrated care just to prove I am wrong!
This is obviously great work. My comment is whether this is true integrated care? Or admission avoidance/urgent care pathway process improvement work? I'm not sure you've described true integration or just great partnership working - just call it what it actually is.
Very well said. Sad that original commenter failed to see the bigger picture of one organisations ability to "achieve integration".
It is duplication we need to reduce and communication we need to streamline and speed-up. Integration is so rewarding to all staff if carried out correctly and the boost to staff moral should not be underestimated.
Chris, excellent blog. I will be reading with interest and forwarding to our acute FT, who already have vertical integration of the Solihull CS. Now is the opportunity to show what can be achieved. Especially like the feedback from Claire and David. It is the Canterbury approach - we are all in this together.
Chris, thanks for the blog. The RF have been at this for a while, and it sounds good. in our place (Sandwell, NW Brum) we just celebrated ten years of Right Care, Right Here. that partnership of agencies and our own determination to reshape what we do has helped us set iCares (a large scale inreach project for those with long term conditions, which David Oliver visited recently), just shifted all our diabetes clinic care over the either GP practice based or mobile-tech enabled, got homeless admission avoidance on the wards run by the third sector, onsite mental health liaison that Louis Appleby recommended, a foecal incontinence inreach to hospital run by our surgeons, and a long list of paediatric examples. Of course most of our services are not "there" yet, but we are a pretty large scale experiment. The shared care record for the city goes nap in the summer which will jump us further fwd. would welcome chance to reflect on lessons learned, of which one is that it is only integrated if that is what patients say it feels like - toby (by the way I have been here nine months so not my success in any way!)
An interesting hospital perspective and particularly interesting is that this is provider reconfiguration described as integration rather than being true integration. This is only to be expected as it is not being driven by commissioners redesigning services but by a powerful and wealthy NHS corporation smartly adjusting to a changing market. “The success being partly due to the Royal Free employing GPs”: integration would be GPs and Royal Free working together with a shift of the funding directly to the GPs as a co-provider. The gap between the scale of the Royal Free with more than £500,000,000 a year income and 5,000 employees and that of a CCG is immense, an average General Practice would be 1/500th the size in terms of income. How can CCGs, let alone GPs working alone and largely unsupported reconfigure the service in such a way that is not to a substantial part shaped by the peculiar interests of these institutions? It seems to me that there needs to be a balance that can only be achieved by General Practice and commissioners driving rapidly to equivalent scale.
How long before admission avoidance gets the same distinction as bed blocking. I have no doubt the work and the process to establish it at the RFH are both excellent and hard won. The real prize will come when proactive care not reactive care becomes embedded.
Comments
At the risk of being considered controversial, I think the whole Transforming Community Services Policy has a lot to answer for. Acute secondary care providers spend a lot of time doing post acute rehab for people recovering from acute illness or injury and a lot of time trying to turn people around and back home from the front door of the hospital. Yet contracts for community service provision have often gone to social enterprises, private sector companies or mental health trusts, none of whom have any form in this area. Why? Because of ingrained hostility to the big bad acutes who were somehow going to asset-strip community services. Yet when we look at "vertically integrated" providers, they have staff working across acute and community, they have the capacity to close capacity in the acute and transfer it to services outside hospital, they can abolish "death by assessment/multiple referral". If you look at some of the transformative work on "discharge to assess" or early supported discharge or community geriatrics, one organisation running acute and community services has proved a boon. Pragmatism over ideology and tribalism
David
Best wishes
Claire
Come and see us too!
David
It is duplication we need to reduce and communication we need to streamline and speed-up. Integration is so rewarding to all staff if carried out correctly and the boost to staff moral should not be underestimated.
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