When integration is about patients not organisations it can work
One of the most interesting issues I have worked on since returning to the NHS has been chairing a group of providers working together from across the statutory and voluntary sector in City and Hackney to design and deliver a system of integrated care for some of the most vulnerable patients in the area. Last Tuesday we sat down to review how our system would work when presented with some of the real life situations faced by patients and clinicians. It was a fascinating and productive afternoon and drew out, for me, some important and more generalisable lessons about what needs to be in place if we are to deliver effective models of out of hospital care which deliver better outcomes for patients and avoid or reduce the occasions on which patients are unnecessarily admitted to or detained in hospital.
The first was the frustration of not being able, routinely, to share information in a timely manner about patients’ history, needs and preferences. In the absence of this it can be all too easy in a crisis situation for an ambulance crew or others to admit a patient as a way of avoiding risk. The availability of the care plan at the point of care might make all the difference if that gave clear details of a pre-established crisis plan or of another source of advice with whom the decision about the risk of leaving a patient at home could be shared. If we cannot share the information electronically (and I think it is still a major indictment of a supposedly National Health Service in the 21st century that we haven’t cracked this) then there must be a place for approaches such as “Message in a Bottle” where a care plan is left in the patient’s home with a visible indication to visiting practitioners of its existence.
The second lesson was about the value of working with patients and families in advance of a crisis to discuss with them their preferences and to work out who to contact and how best to manage when a difficult situation did arise. This kind of preventative work ought to be the heart of effective care planning and can do so much to ensure that all parties are prepared in the event of a crisis when decision making inevitably tends to be less than perfect. It also reflects the opportunity to build up the kind of trust between patients, families and health and social services which make shared risk taking that much easier to deliver.
Some of the cases we considered highlighted the challenges of fitting care around the, sometimes messy, complexities of patients’ lives. There is a difficult boundary at times for practitioners working in circumstances where they have concerns about individual’s home circumstances. However either ignoring those issues or being too judgemental helps no one and where, for instance, such concerns turn a routine day admission into a hospital stay of 4 months the system is not working. Resolving such issues often play better to the skills of social work and the voluntary sector and they need to be given the opportunity to work with patients to find a way forward which works.
Time was often the key factor. Where a range of interventions whether clinical, or as often social or practical, could be accessed quickly then it would be possible to keep a patient at home. If not then a hospital admission inevitably became the default position. Alternatively the issue of time related to the ability for busy clinicians to spend the necessary time when required to contact other services and negotiate the necessary support. At times, even for the most dedicated clinicians, that became too difficult and, again, a hospital admission became the only viable option. In City and Hackney we have recognised the need for including in our model individuals who have the capacity and authority to resolve such issues.
The final lesson was in the very process we were engaged in. Facilitated multi-disciplinary discussion of individual cases helps identify what works and does not work in the way in which practitioners and organisations work together. Where this is done in a supportive and “no blame” manner and where action can result from the lessons learnt then it is possible to organically improve the integration and outcomes of care. Again such a “learning system” is central to the approach we are trying to put together in City and Hackney.
For me this was a good week for the integration agenda. The excellent report of the Barker Commission, published on Thursday, set out a compelling case for addressing the structural dysfunction of separating health and social care. Tuesday’s workshop highlighted for me how, at the local level, that when practitioners and managers are focused on patients not on organisational processes and interests real steps forward can be taken. That’s got to be the goal.