Dr Peter Mayer - Integrated Care Blog

Re-inventing a Long Term Dream: Do we need new systems to deliver “working together” We run a huge risk of repeating the mistakes of the policy 10 (PPM ?70) years ago, thinking that integration is solved just by fiddling with organizational form options” M. Winn 21.5.2018 I have had a career long passion in delivering services across sector boundaries as geriatric service lead of hospital and community health facilities, running the Institute’s Excellent Care Award, participating in the development of Stroke Illness pathways , and as a former chair of joint planning in Birmingham. My purpose with this publication is to seek examples of Good Practice, building on our experience from the “Excellent Care Award” to inform the work now being done under the new national drive to promote integration in commissioning and in delivering health and social care. The driver for this strategy is the long-standing perception that underfunded fragmented poorly delivered services can be reorganized to provide cost effective services with the person in need at the centre of the change required. The World Health Organisation (WHO) and NHS England (NHSE) see the patient/citizen as the pivot round which service configuration should be structured. But most service planning is initiated centrally and in the recent Sustainability Transformation Partnerships (STPs now becoming Integrated Care Systems (ICS)) the service user seems the last group involved in planning and driving service change. NHS clinical commissioning groups (CCGs) do have a requirement to consult their populations and some are doing this well but many are too small and lack the skills to deliver.

Mergers to bigger commissioning organisations, as recently agreed in Birmingham and Solihull, may help address this? Mental Health services may, more frequently, have developed successful models of population involvement in service development and I would argue that the research community has also developed robust models of public involvement in priority setting, design and delivery of research outcomes. What is integration and is the present focus on health and social care the correct focus. There seems little emphasis on implementing health promotion and disease and disability prevention in reducing long term systems overload. Public Health interventions remain an essential driver for improving long term outcomes and should be in all integration contracts. The WHO definition states: “Integrated Care is a concept bringing together inputs, delivery management, and organisation of services related to diagnosis, treatment, care rehabilitation and health promotion. Integration is a means to improve services in relation to access, quality user satisfaction, and efficiency” NHSE have adopted a definition co-developed with National Voices: “I can plan my care with people who work together to understand me and my carers allowing me control and bring services tog In a Grant Thornton (GT) workshop on Integrated Care Systems 11.6.2018 Presented by Prof Andy Hardy (CEO NHS Trust and STP lead Coventry) and Peter Saunders (GT) emphasized the difficulties but described positive indicators arising from STP discussions and GT support in contracting. Difficulties included: - lack of skilled leads in e.g. integration of back office functions and workforce management - Lack of meaningful public engagement - Major difficulty in delivering local change with very slow progress - increasing block contracting reducing drive for innovation and transparency Positive indicators included: - Increased communication between organisations and their officers - Support for modernization - New models described: included Royal Wolverhampton NHS FT directly employing GPS and financing their service improvements, South Yorkshire 12 organisations serving 2.5 million populations close to agreeing new integrating contracts. They suggest that 30% of outcome is due to systems change but 70% is due to public and staff engagement. - That the new contracts based on driving quality and outcomes. . NHSI states that successful models are based on all people in the system having a shared philosophy and core values, mutual trust, mutual gain, good process leadership, a focus on the priorities that matter and an avoidance of power dominating discussion ” NHS Providers 11.6.2018 suggest that “NHSE and NHSI should make clear that they actively support local areas in communicating and co- designing service changes with local communities and elected representatives. This parliamentary select committee report(7th Report - Integrated care: organisations, partnerships and systems | House of Commons | Health and Social Care | HC 650 | Published 11 June 2018) found that more integrated care will improve patient experience, particularly for those with long-term conditions. However, while it may reduce demand on hospital services, the Committee concluded there is a lack of evidence that integration, at least in the short term, saves money. Useful local evidence from Healthwatch Birmingham is published in the report. (11.10.2017.) ” We are yet to see a clear process of seeking patient and public insight, experience and involvement within our local STP nor is there a consistent strategy developed for each stage of the plan. Having an engagement strategy would ensure that patients, the public, service users and carers understand the implications of changes to their health and social care services. Equally, it would ensure that they feel engaged and informed throughout the process and that their thoughts, ideas and comments are taken into account to develop these plans further.” Read NHS Providers “On the day Briefing” if you read nothing else: Read this summary of the main findings and recommendations in this report. HSC OTDB 11 June 2018.pdf I would totally concur with Roy Lilley (NHS that an essential outcome is a library of successful models and, let us, by collecting these from the West Midlands play a small part in the education of those trying to implement integration and avoid the obsession with only funding something NEW. PPM 25.6.2018

Due to the delay in publication the reader might wish and should consult the "hot off the press' government response to consultation:

Government response to the recommendations of the Health and Social Care Committee's inquiry into 'Integrated care: organisations, partnerships and systems' 

Seventh report of session 2017-19Presented to Parliament by the Secretary of State for Health and Social Care by Command of Her Majesty August 2018 Cm 9695 

This is the response to the Health and Social care paper of June 11th:

 To quote a few paragraphs in full from its executive summary:

"Integrated care is centred around a person's needs; proactive in supporting wellbeing and identifying risks of health deteriorating; and coordinated so that it feels like it's provided by one service, even if it isn't. It should improve health and wellbeing for the population, enhance the quality of care from providers, and improve financial sustainability. Integrated care also involves a greater focus on population health. This will need the NHS, local authorities and the third sector to work together to enable the development of new models of care that focus on populations and their needs and, prevent ill health and unnecessary hospitalisation." 

"-a 2014 meta-review of integration found beneficial effects of integration of care on several outcomes, including reduced mortality, reduced hospital admissions and re-admissions, improved adherence to treatment guidelines and better quality of life."

So a very much in favour report which talks about ring fenced transformation funding but suggests this may already be from the 3.4% 10 year plan increase announced. They see STPs as the basis and from 10 existing ICS and suggest a "joint national transformation strategy"  including the DoH, NHS England, NHS Improvement, Health Education England, Public Health England and CQC.

And a conclusion which I suspect will not be accepted by many:

"We also welcome the Committee's recognition that integration will not lead to privatisation nor will it threaten the founding principles of the NHS – which will always remain free at the point of use."  

Dr P P Mayer


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