But integrated care can mean different things to different people and there is no one model or way of doing it.
To help inform our work, we asked you to let us know what good integrated care meant to you. We updated this page, and our Wordle, as we received your responses via the website and Twitter.
Your views on integrated care
Here are the responses we received:
From my experience in medical and psychiatric hospitals, I found that good case managers can reduce the fragmentation of services. In a sense, the case manager is a patient advocate that assures the integration of all services the client requires. The case management approach, when done right, assures that the patient needs come first within the organization, and that the required services are provided in the most efficient manner.
Integrated care means seamless transition between health care professionals, that provides not only holistic but individually tailored.
Integrated care requires that various people who contribute to care work in synchrony. Care plans, multidisciplinary teams and coordination of activities all help this to happen. But good integrated care requires much more. It requires mechanisms that facilitate on-going creative interaction between practitioners and managers throughout Health and Social care - in the vertical direction between generalists and specialists, and in the horizontal direction between primary care, social care, voluntary and user groups. Most people in the NHS are unfamiliar with the methods that can achieve this scale of relationship-building – it requires empowerment more than control. The poverty of integrated care in the NHS should not be surprising – we all know how difficult it is to build trusted relationships, and how easily they break down. The NHS is large and full of divisive structures. Practitioners are trained in one-to-one care and not in whole system collaboration.
Paul, Clinician, Board member and academic
That care provided to an individual is organised in a coordinated and timely manner with all relevant agencies/professionals speaking and listening to each other and to the individual and his/her spouse/family etc. That all involved have the opportunity to discuss what is needed by the and with the individual to ensure they can live as independently as possible. That what is needed is provided when and where it is needed and by the most relevant professional/agency. That those agencies/professionals know and understand what each others responsibilities are in respect of the person receiving the care (and significant others such as spouse/family carers etc.)
Speech and language therapist and former carer
Good communication between different agencies offering a service to the client, sharing information and working in the interest of the client. Good access to services the client needs - easier referral route and better level of services available and less waiting for the services to be delivered e.g access to Speech & Language Therapy for people with neurological conditions such as Parkinson's disease. Better paid and motivated care staff. Good organisation of care services based on client need, not convenience of service, so that clients are able to have a small number of the same care staff helping them with daily needs such as washing.
For long-term chronic diseases integration, in my opinion means to add behaviour lifestyle changes and self management skills to a comprhensive medical treatment plan. This implies a strong coordination among all services (medical and community non-medical) needed to addres multidimensional needs of these patients as well as medical and other healthcare professionals.
At a minimum, integrated care means having one person assigned to coordinate provision of an individual's various care needs and to be the "patient's" link person. Ideally such "link persons" would be accessed via the GP as this is the most familiar access point into the NHS. A "link person" does not have to be a carer or clinician - but must be good at relating well to elderly / anxious / confused people as well as to different professional agencies. I have in mind the skill sets that Citizens Advice Bureau workers are expected to have / are trained for.
Michelle, Foundation Trust Hospital Governor
It means that all those who have a role in your care, understand your needs and have all the information they require to support you including up to date care plans. It also means that you are considered as a whole person rather than just a disease.
While ICP model is founded on good principals it often fails in it delivery due to poor communication within the multifaceted team leading to meetings after meeting and then reviews, culminating in loss of financial resources and time that directly impacts on the care of a person. while there has to be a substantial management structure how many of these managers are thinking of their budgets and what minimum they can get away with supplying rather than an open book approach that has no constraints placed upon it. Within the private sector nursing homes are faced with more and more discharges that are coming through that are wrongly categorised in an attempt to save money. An example of this could be seen as a person coming into care that is categorised as “Higher rate residential” when in fact their needs reflect the care more suitable to that of Nursing care or even palliative care. All those mentioned I have dealt with on numerous occasions and yet the onus is on the care / nursing home to take them on regardless.
Palliative care co-ordinator
Integrated care means teams being at least partly responsible for what happens after patient leaves
As a front-line clinician, medical manager and unscheduled care lead, I'm actually enthused by the strategic position in which we as a health economy now find ourselves. With emergent CCGs charged with collaboratively describing the clinical landscape, the opportunity arises to be bold and re-articulate traditional care. Fractured and fragmented boundaries and barriers can be removed if we root care in pathways which make sense to patients rather than those which best serve illogical needs. Frail elderly care is a prime example. Let us agree that the home, or nursing home, is the default context-of-choice for the elderly fail person. To maximise health requires daily, weekly, monthly nursing and social input supported by proactive and reactive medical vigilance - in other words, a really effective community health and social team. When acuity worsens, the team are the first-call response, not an ambulance. When an ambulance is thought necessary, the community team are consulted first. If hospital is deemed necessary, that community team track their patient throughout the hospital episode, in-reaching in the Emergency Department, the Admissions Ward, the CCU, wherever - planning discharge, refining the care package, ensuring the community response is readied and appropriate. And, when acuity lessens, they facilitate swift transport home, all of this supported by fit-for-purpose information sharing. This is the key approach to care now. Root our health services in pathway design and resource those high-volume pathways sensibly. Costs will be driven out through scrutiny. But it needs leadership - followership, too - and bravery on the part of commissioners and providers. Are we up for that challenge? If so, the time to act is right now.
Darren, Clinical Director, Unscheduled Care
Good integrated care involves the statutory sectors trusting the voluntary sector and allowing access to the care of the elderly in a much greater measure than is currently available. It is time to reduce the inequalities and ensure that older people are provided with a high quality of care with a joined up working programme both within the NHS, Social Services and the voluntary sector. This would lead to the recognition that the voluntary sector is extremely cost effective in keeping older people living at home, out of hospital and living happier and healthier lives. Include the voluntary organisations in the care plan meetings, reviews, discharge from hospital, etc - not as a second thought, but as a recognition of the vital role that we play in the care of the elderly. We are so often their advocates to the NHS and Social Services, we are also the secret inspectors for the services that our older people find they have to participate in - it would be so good to work together.
Mo, Board Member/Director
Good integrated care is joined up care across different services and providers. It also embodies efficiencies in delivery highlighted by lack of duplication, smart IT, and wrap-around care. Is is possible? Not currently; the current focus on Key Performance Indicators, Service Level Agreements, Any Willing Providers, and short term goals and rewards, dis-incentivises integrated care, which is more of a long term aim. By definition, integrated care as an image would be a circle without a start or finish. You can join anywhere on that path and be assured that you are on a continuum. Instead we have slices of a pie with each slice trying to be as big as possible! It is not in the financial interests of almost all providers to provider integrated care - either because they are trying to protect their service and staff, and/or to ensure that they have adequate Return on their Investment.
For me, integrated care is about doctors taking responsibility for me as a whole patient who has to live in the 6 months between appointments, and is concerned with the wider picture of my emotional health and lifestyle, not just the disease of which they are an expert in! For example, as a patient with 5 conditions I long for one doctor who will take into account all of them and the change in my life because of them, and bear it all in mind when considering the next steps. It would mean having a solution when admitted to hospital, instead of being discharged by the general acute staff once the issue I was admitted with in under control, with the underlying causes still un-addressed.
"professionals working together to co-ordinate the care these people need" It seems that again the patient is not asked! Working as a GP I am acutely aware that health professionals keep being problem focused and trying to direct the patient to other professionals. Every health professional needs to be able to empower patients with brief solution focused consultation techniques or motivational interviewing techniques. It is known for a long time that giving advice doesnt help. Patients know their needs best and it's about helping them to take care of their own needs.
Integrated care among the elderly means assessing for frailty and/or health risk assessment, communicating the risk associated with those assessments to the patient/family, and then organising care needs that meet both the patient's needs and expectations. So, as caregivers we must provide as much continuity of actual "people" in different settings, and where new providers exist (consultants, home care providers, nursing home, etc.) we must ensure that those staff understand the patient's risks and expectations for care as well from the outset.
Integrated care is doctors taking responsibility for whole patients not just one of their health conditions
Integrated care is multi-inter-trans-disciplinary (incl patients) co-management including prevention
I have to say that I am very pleased with the way my few care needs are dealt with: a) a GP's Practice Nurse visited me and seemed to have spotted my needs immediately, thus arranging walking aids, shower seat, personal hygiene supplies, then b) via another Practice Nurse keeping sugar levels under control and enrolment on a healthy lifestyle and fitness programme at a a local centre then a local gym In effect I suggest that much depends on Practice Nurses. Maybe there should be more of them
Integrated care means all concerned in delivering care to patients with various health needs are well co-ordinated to provide care and support in-line with needs. It is about person centered care to individuals at all times.
Effective integrated care needs to include addressing people's living conditions as these are a major determinant of health and care needs. Delivery of health or social care at or closer to home is a key policy objective; to be delivered effectively the standard and suitability of a person's home is not taken into account? The majority of health and social care is required by older people, 90% of whom live in ordinary housing not institutional settings, therefore fully integrating housing related support has a key role to play in care and health provision.
Sue, Charity Sector
Integrated Care to me is about someone considering the whole person, listening to what the issues are for me, and not simply the specific symptom. I spent 8 years having specialist treatment for respiratory problems. Only after this period did I see a nurse consultant who- unlike the doctors- spent half an hour with me not the 10 minutes the consultant usually spent. This gave me time to tell her that whilst this was a respiratory clinic what was really bothering me was the pain in my sinuses. Two years, three operations, a referral to ENT and an Immunologist later, I am on the way to recovery. It's just a shame that in that first 8 years of people looking at my lungs, everyone was too busy to have a look at the bits that were directly above my lungs and were causing the actual problem.
Patient and NHS Manager
integrated care for me is when all concerned in the delivery of care to all indviduals are effectively commuincated about my needs and the best way to support me to do the best i can for myself. it is about my care team listening to me and not assumptions. The care team are professionals and should act as one at all time and respect the ability and knowledge of the patient so that they can give the best possible care. Integrated care is about care delivery centred on the needs, preferences, and belief, it is about me.
Cutting across organisational barriers/cultures to achieve real meaningful outcomes for individuals - Looking at needs/outcomes before money - Outcome focused / Contributing to the whole outcome and not wanting to own it. - Identifying and measuring real outcomes and success (not counting buttons)
Noreen, Business Change Leader
Proactive, simple joined up
Judith, Board member
Integrated care means: My being able to go to A&E to assess an older person who has taken an overdose, document that I cannot make a complete assessment as the patient is too acutely confused. Plan to return within 24 hours. Without being made to feel I have failed and am to blame for 'trolley waits', failed A&E targets and overly long lengths of stay.
Bringing all leads in the whole care pathway together in a multi-professional approach. Having a lead clinician and a lead administrator for the bundle of care pathway with a clear point of access and a simple route of feedback from user, clinicians and GPs. Clinical Commissioning groups to look outwards and work with Health and Wellbeing boards and Local Education and training boards.
Good integrated care means a determination to improve lives by utilising systems for the purpose for which they were designed i.e. providing intelligence to inform strategies
Andrea, Information consultant
Integrated care is seamless care from the patient's perspective - no boundaries,no gaps,health and social, 1ary & 2ndary
Integrated care means means a seamless 'one-stop-shop' style service thats easily accessible from one point
integrated care means me telling my story once and others listening deeply to what I say is important to me. It means care designed around my holistic lifestlye needs as much as my medical needs. it means care that builds upon who I am and what I enjoy and am good at. Integrated care has me at its centre. The integration needs not to be about professionals co-locating or multidisciplinary teams or pooled budgets it should instead start with a focus on meeting my holistic needs, once that occurs the rest can follow. integrated care = citizen centric care.
Dan, Care charity
It is easier for me to start by saying what integrated care is NOT: it is not a system whereby the doctor in charge of your overall health (your GP) is given a guideline of 10 minutes per appointment and one complaint per appointment. Integrated care is a system whereby GPs have the time for a lengthy appointment, when necessary, to take into account all the patient's symptoms and to do a physical examination so that s/he can develop an idea of an appropriate diagnosis and referral and medications, where merited. Integrated care also includes the freedom for GPs (or other prescribing doctors) to go outside strict protocols determined by a governing board when prescribing medications or recommending other treatments. Integrated care acknowledges that each human body can be radically different in its presentation of illness and in its response to treatment, and that therefore, treatment must be modified as necessary.
Good integrated care requires all community staff to be trained to a level that they can acts a key worker for clients ensuring that all necessary services are involved in a persons care. Staff need to be able to look wider than just what their service can offer. All the time I meet clients at home who have professionals just looking a single problems and avoiding the greater needs. Case management model where clients have a keyworker to co-ordinate and enable the client to manage their own care could be implemented more easily than re-organising services. The key barrier is cultural where health and social care professionals still continue to work in splendid isolation.
Sarah, Wheelchair service manager, Physiotherapist
AND for patient too! Feels person centred joined-up service where everyone listening & working together!
Integrated care is patient-centric, not provider-centric. The patient's web of care covers not only multiple health providers but also social care and voluntary services as well as carers friends and family. All need to be kept informed, which requires changes to the way we share information and putting the patient firmly in control. By its very nature integrated care crosses organisational boundaries and we must recognise that solutions that may work well within organisations do not scale across their perimeters. When sharing information, we need to clearly distinguish between the sort of data that is only there to support providers' internal processes (and should not be shared) and that which it is useful to others.
Tim, Health Informatics
Integrated care is whan a person gets care for their needs - NHS and/or Social services and does not know which organisation is providing it
integrated care is the active collaboration between clinicians and social workers to reduce inequalities in patients also in order to achieve better health outcomes and measurable at a reasonable cost
Integrated care is not about creating structures. Ask any service user - do you know how your care plan is delivered? If the answer is 'no' (but I get good care), then the services are integrated.
Care which is wrapped around the patient, with health and social care working closely together to the meet identified needs and goals of the patient. Collaboration with patient, carers and other providers. Reduction of duplication and waste. Good care co-ordination. A named contact for the patient and a clear plan. Sharing of records to promote efficiency and safety.
It means embracing systems thinking and complexity
I think most of us who work in active self-management know what it is, but not sure the decision makers at CCG's / PCT's / & health care professionals know what it is.
Pete, Former Patient
Integration has to be from a service user's point of view, in that the support provided should be organised to reflect the combination of user's needs in terms of delivering the right interventions from the right provider at the right time and in the right place (forgive the non-oriniality of this, but it is very important), so that the whole need is met in a co-ordinated fashion where providers/ professionals have a complete view of the user's needs, understand who else is or should be involved, and deliver support and advice in a co-ordinated fashion. Interactions between staff and service users should be underpinned by sharing information and evidence about best practice and effectiveness.
David, Service Development Consultant
In North Somerset we're working with: "Integrated Care is a more joined-up way of caring for people. It means staff in health and social care working as a single team to make sure people get the support they need, when and where they need it, without confusion or delay."
Integrated care = no gaps. Relentlessly reducing delays, duplication, defects and disorderliness
Good integrated care means ease of access,clear communication of expectations,outcomes and social care!
Integrated care is for me a multi agency, seamless approach to assessment and care management , that is proactive rather than reactive and has ongoing assessment at the core of a patient/carer centered system of care delivery
Integrated care = focusing treatment and support on keeping the patient as independent as possible, with best possible quality of life.
'Integrated care' means that my emotional, social, mental, physical and spiritual health and well-being are enabled and enhanced and supported within the service structures in a form that is accessible for me, a vulnerable person who has issues that need addressing on every level. I do not want to be passed from pillar to post and back again, nor given cheaper options that do not address my needs, and I expect my 'take' on what is workable and what is not, to be taken on board in any prescribing of treatment, including particularly, mental health treatment. There needs to be an understanding that social and emotional aspects of my being must be served and my own choice of spiritual approaches to my difficulties are also valid. Those involved in my care need to work 'as a team', and communicate and share analysis of my struggles and discuss with each other as well as with me, meeting on a regular basis, how I am doing and how best we can go forward. My input should be seen as particularly key to what strategies of help are delivered. 'Integrated care' also means that if I am able and willing, given my disabilities, to engage in my choice of voluntary or paid work for my well-being and development, I will receive the necessary support from services (identified and approved by myself) and funding to enable me to do it.
Good integrated care is a seamless, boundary-less service that is focussed on the needs of the patient rather than competing organisations or those of central gov. Integrated care organisations also need to be realistic about their remit and ability to deliver so that the expectations of patients, carers and other clinical colleagues are properly managed.
Integrated care should be seamless and uncomplicated for patients, carers and health, social care and third sector providers.
Integrated care comes when we design things with people, recognising we are a guest in their life rather than to suit us
Integrated care means having a champion with teeth that can help the patient with complex medical needs to join / get access to all the different agencies, consultants, medical staff, making them work together to formulate a short / medium / long term plan for that persons overall health and care provision. making sure that that plan is put into action, + having accountability for that person's well being.
It means that each person offering support, help and care to another person has that person's interests at heart, knows their circumstances, what help is provided by whom and when and what the person needs to live a good life (not just have good care) This means responding in a holistic way, ensuring no duplication of services or calls for information from the person and no gaps in care either. It must, however, also mean looking at where and how they live - is their housing as suitable as it can be to support good care? Can it be improved or adapted for example? A feature that is often missing when people talk of integrated care.
Integrated care is about solving problems for patients...that has to be the starting point, or else why integrate for the sake of it?
Integrated care = care that feels joined up, person part of a team in which all share info, talk to each other and have a common goal
Integrated services work best when they promote increased user involvement, choice and control. However, the Social Care Institute for Excellence's (SCIE) recent review found that service user and carer views are not routinely collected in evaluations of joint working. Yet defining outcomes that matter to service users and carers is important. Service user-defined outcomes may differ from policy and practice imperatives but are a crucial aspect of understanding the effectiveness of integrated services from the perspectives of people who use services themselves
Good integrated care is responsive community services on a 24/7 basis. Budget holders need to prioritise short term interventions to restore independent living status.
To me it means that things are joined up, not fragmented into different parts with no one person informing all the relevant agencies about your needs and condition. Importantly also integrated care must include the persons wishes and needs, too often at the moment the person is left out of the loop! In my experience I am 'told' what I can and cant have irrigardless of my needs and wishes. This is the same for many unfortunately.
is having a patient champion wth teeth to pull all diff interested parties together for pers needing complex integrated care
Good integrated care means a health system that is responsive to my needs and where the medical professionals who treat me are - problem solvers - who are aware of their colleagues' skills and resources so that they are able to point me in the right direction when they aren't able to help. At the heart of my care is a specialised team who have the training, knowledge and experience to treat my most significant problem and to advise any other professionals that I need to see on the consequences for them of my problem. Good integrated care does not mean restrictive care pathways that mean that rather than being problem solvers medical professional are reduced to people who can only provide a few treatments within an extremely limited scope, meaning that I have to go from person to person looking for someone whose job description fits covers my problem.
Personalised and co-created outcome focussed support that develops and changes with a persons needs and circumstances.
seamless care across pathways
It means Individual Budgets and close working - possibly even integration - with Housing too
Integrated care is.....not letting debates about whose budget will pay (NHS and/or social care/housing) get in the way of delivering a responsive and effective service. Also, it's thinking in a more holistic way about individual needs - including housing, transport, environmental issues, community safety etc. All of these issues affect the health and well being of individuals and should be factored into any integrated care provision.
I believe very strongly in Integrated care pathways. It improves with communication, planning for a safe discharge planning. The ICP should start from the GP services /A and E . ICP could be colour coded for example white colour for the medical team,green colour for an Occupational therapist, blue for Physiotherapist, etc. This helps to improve quality of care and minimise the near misses.
Properly coordinated care for people with rare conditions as well as the commonly discussed care pathways, e.g around cancer, diabetes, copd. Not having to repeat or explain your story to each individual seen in the system. A sense that somebody has taken ownership of your case and is navigating you straight to the right part of the system, rather than wasting time, and money referring inapropriately to people who cant help. Systems feeling from the patients perspective that they are joined up. Minimal unnecessary and inneficient bureaucracy.
empathetic,effective ,inclusive,taking account diversity of thinking by managers &clinicians &patient needs.wellness!
Integrated care means taking an end-to-end view of patient and having one set of performance measures across all agencies