Building Integrated Care conference at Kings Fund: Views from Singapore, US and Europe

Key impressions

A starting point was work in Singapore with development of transition teams to ensure continuity of care across the patient journey. Seamless care without delays between services is perhaps a fundamental of all integrated care programmes.

Tweet@nchadborn:

Jason Cheah>need to go beyond Wagner model of chronic medical care to include social care #integratedcare

Tweet@Innovation_Unit:

Jason Cheah: have to be aware of pilot-itis and change fatigue. some patients get stuck between pilots & rapidly lose faith #integratedcare

Leadership is a key issue, with one speaker pointing out that integrated care is now a management and leadership challenge, rather than a technical one. It was also noted that the frequent recommendations for ‘leadership’ rarely go into more depth than that, and actually what is required is detailed practical information about what is involved and how to go about it effectively.

Contrasting views

Many programmes involve population-level disease registers or registers of people who are ‘at-risk’ of being admitted to hospital. Programmes use registers to target people with specific diseases, requiring palliative care, suffer from complications of diabetes, or are at risk of having a fall. This contrasts with a more rural programme with small GP practices, who feel that their personal knowledge of their population is superior to a register.

A common view was that programmes should be big enough to yield significant efficiencies. This was described as needing to be big enough to release whole-bays of beds in hospital, otherwise there wouldn’t be sufficient recoverable savings in order to invest in community care. On the other hand another view was that the size task of integrated projects should not be underestimated and that projects should start small. There were similar contrasting views expressed about incentives and choice, an English view was that there was a need for comprehensive reform of payment structures to ensure that integration is the preferred option (and presumably to avoid potential perverse incentives). However the continental view was that commitment to integrated care has to be voluntary, to preserve both patient choice and doctor autonomy.

Physical location was thought to be important, with co-located services enabling personal interaction between the multidisciplinary team members. However, in line with the strong discourse of benefits of information and communication technology, the alternate view is that virtual integration can be preferable, particularly when it is combined with in-depth computer analysis of patient risk level and quality controls.

Finances and accountability were a common thread through the day. Bundled payments were described as ways of commissioning care for multiple service needs of people with long term conditions. One view centred the bundle on the hospital and cautioned that all partners should take equitable shares rather than the hospital dominating. However the Dutch experience indicated that bundled care was centred on community care and that when an acute episode of the illness occurred, the bundled payment was paused and separate hospital financing took over (this indicates horizontal integration, with no integration of hospital and primary care).

Case Management

Case management has been the focus of many UK pilots including the majority of the DH national evaluation. But what does good case management look like? A recent KingsFund report states that it requires one person has accountability (although another speaker described team shared accountability). The case manager has the following diverse roles

• care provider
• listener
• feedback to teams
• care coordinator

Thus case managing is acknowledged to be a very specialist role – requiring appropriate recruitment, training etc. The person specification should not just be about clinical excellence; emotional intelligence (EQ) probably more important.

Case management programme design:

• Targeting and eligibility to programme (getting thresholds right)
• Manageable caseload (dependent on above)
• Single point of access and single assessment (importance of assessment sometimes overlooked)
• Continuity of care
• Share data effectively (ICT)

A London based integrated health and social care programme included routine health assessment for half of population of older people in community every year. From this assessment, people who are at risk of deteriorating can be targeted for intervention. Case management can then prevent exacerbation of long-term conditions. However this raises another contrasting view, as a previous speaker had indicated that case management interventions should be time-limited, whereas a preventative intervention has to be ongoing, almost by definition. Of course there may be differences in definition and practice to explain this contrast.

Case management has a risk of becoming a bureaucratic process, as it may drift towards focusing on coordinating health professionals, rather than its patient centred origins. However at its best it empowers patients with shared decision making. It is equally important to involve the informal caregivers (partners and relatives) at this stage. Furthermore this can go beyond individual or even population perspective of the programme; patients who have been through the process could be professionally engaged to give support to current patients, as well as facilitate improvements to the programme, not just expert patients, but professional patients. There is potential here to link with the ‘health and wealth’ agenda, although some concerns may be raised of developing a disease-dependency culture.

Regional examples

The programme in Northumbria developed a Community Business Unit which was relatively independent from the partnership Foundation Trust. They found Transforming Community Services to be a natural progression of their work (as opposed to several other pilots within the DH programme which felt that TCS disrupted their programme). While some speakers thought that quick wins were important within public sector delivery, the experience from Northumbria was that it should be expected to take 5 years for programmes to bed-in.

Another example given was the Quebec PRISMA programme. This ‘single point of access’ system was successful in the city, but has encountered difficulty in rolling out across the province. The speaker indicated that this may be due to a difficulty in maintaining strong leadership, following an impassioned leader setting up the programme. Sustainability of innovation is a key aspect of implementation of research and policy and forthcoming seminars by Prof Graham Martin, in Leicester (video will be available online) and Nottingham (also available online) will present research in this area.

In my opinion there is also a geographic factor at work in the Quebec example; where programmes developed in urban areas may not ‘plug-and-play’ in rural areas. Similarly the Northumbria experience may be difficult to replicate in conurbations.

Findings from the Netherlands and Germany were that it was important to have a Network Manager who had a strategic oversight and some degree of control over the care providers (GPs and others) and the service providers (lab tests, medicines, ICT). It is not clear whether this is the model which will develop in England, but if so, CCG’s may step into this role.

Tweet@nchadborn:

Helmut Hildebrandt>need network manager org for strategic input #integratedcare apply theories from many disciplines incl org psychology

Tweet@nchadborn:

Hildebrandt> good data on improvements for hospitalisation and survival #integratedcare with comparator group in Germany

In Germany there were two partners to the integrated programme; a multidisciplinary physician network and a management company, this may in some ways reflect the social health insurance financing model. A key question posed by one of the Dutch presenters was – what would it look like ifhealthcare was delivered like airlines:

Two speakers from US discussed accountability and finances. One proposed that it was essential that financial incentives are aligned with capabilities to respond, that is you shouldn’t expect a financial package to do the whole job. The other emphasised the need for a triangle of accountability, capabilities and incentives.

The final session was on commissioning within the new structures of NHS England.

Tweet@TheKingsFund

MMc: inputs for integrated care for LTCs- pts in charge, proactive & accessible prim care & coordinated health & social care #integratedcare

Dr Martin McShane (NHS CB): NHSCB will have to work in partnerhsip and enable CCGs to commission effectively for LTCs #integratedcare

Tweet@nchadborn

@docmdmartin >admission to hospital of someone with long term conditions should be like tripwire for community health

@docmdmartin >admission to hospital of someone with long term conditions should be like tripwire for community health

Two representatives from Monitor assuaged concerns that anti-competition rules would constrain integration. Of course Monitor prioritises quality of patient care over encouraging competition. Based on the assumption that integrated care will improve patient experience and outcome, Monitor have stated that they would not investigate integrated care programmes for claims of anti-competitive behaviour.  However given the doubts raised earlier in the day that integrated care doesn’t necessarily improve patient outcomes or experience, organisations may still cautiously await further reassurance (and guidance documents) from Monitor.

Tweet@docmdmartin

Monitor expects individual cases of integrated care to be dealt with through self assessment using rules guidance &advice #integratedcare

My ‘typical academic’ take on the day was that it raised more questions than answers. Furthermore several speakers emphasised the need for continual evaluation to support ongoing development and improvement and the need to communicate these findings nationally and internationally, and of course academics are best placed for these tasks!

More soundbites:

“...requires huge amount of work and communication...”

“...prevention, effectiveness and efficiency...”  and “salutogenesis”

“...the most important person in the integrated team is the patient...”

http://storify.com/nchadborn/building-integrated-care-king-s-fund