The winding road to integrated care | Niall Dickson

Niall Dickson

Devon is one of the more challenged health economies in England and so it was interesting, and enlightening, to see its leaders come together in the last week and grapple with the reality of what it will mean to become an integrated care system.

In some ways, the burning platform on which they find themselves makes it hard for them to find the time as leaders and professionals to concentrate on a new and different future.

On the other hand, there is no alternative. At that gathering, and increasingly throughout the health and the care system, there is a recognition that the current system is not fit for purpose and we urgently need to move to something fundamentally different.

It was a view echoed at the first NHS Forum event, which we convened in Cardiff this week. This brought together senior leaders involved in bringing about integration in each of the four health services across the UK.

The nature of the challenge is the same – all our services are unsustainable without radical reform. We are all struggling to meet demand now, and were we to rely on our 19th and 20th century models of care, services would rapidly be overwhelmed. Demography, expectations, technical advances, and a mammoth workforce crisis mean more of the same is not an option.

The good news is that there is a direction of travel within all four systems that offers at least the prospect of mitigating the inexorable rise in demand. There are enough green shoots to provide some evidence that we are not on a fool’s errand.

Taking the Christchurch model of integration as an example, they can point to a 25 per cent drop in A&E attendances compared with the rest of New Zealand. Looking closer to home, in Aberdeenshire, they have flattened A&E attendances and admissions, despite population growth and the usual array of factors that usually drive increased demand.

It is a similar story in Salford, where integrated services, using a different model, have relieved pressure on the acute sector and have in turn enabled further investment in new models of care. Of course, there are many other examples, including the extraordinary progress in Wigan.

The gain is not only in providing relief for overstretched hospitals, although the benefits of that are extremely important, for patients and staff, and for the extra muscle it gives the case for reform. We can also see more effective and appropriate care and treatment at the right time, moving a system from emergency to scheduled interventions, and then to the holy grail: preventing the need for interventions.  

The challenges are at least well understood. They are shared across the UK and, one suspects, across developed healthcare economies the world over. The starting points in most systems include building trust and relationships, changing leadership behaviours, engaging clinicians and communities, and learning to work as one system, preferably with one budget focused on the health of the population, including wider determinants.

There is another dimension, too – in Scotland, they have Realistic Medicine and in Wales, Prudent Healthcare, which have helped to initiate more grown-up conversations with clinicians and the public about individual responsibility and self-care. It will require handing over information and control to patients and users themselves.    

All this is easier said than done. Changing the culture and dynamics across a system takes time, and many who have embarked on this describe it as among the hardest journeys of their career. It is made even harder when new accountabilities are simply added to the old ones.

It also requires new mindsets throughout the system. Even within the NHS, we are still plagued with fissures between primary and secondary care, between physical and mental health, and between different professional groups. To that must be added the artificial and counterproductive divisions between local government, the community, voluntary and independent sectors.  

None of this collaborative talk will mean anything without new delivery vehicles at the sharp end. We need multidisciplinary teams using interoperable IT and data to segment populations, and to provide bespoke interventions in order to target resources and reduce duplication. The walls of the hospital are disappearing as specialists help to reshape pathways and share their expertise at an earlier stage.

It is still a gamble – the hard evidence of the impact on demand that will be required is encouraging, but embryonic.

We will be writing up the NHS Forum on integration in the UK and will shortly be publishing evidence from other countries. Even if everyone is approaching this in their own way, there is much to learn from each other as we all strive for the same outcomes. At the same time, we must guard against the danger that politicians will not give us the time to turn the ship around.  

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