What is the case for change?
Integrated care is what service users want to have, what providers want to be able to deliver and what commissioners want to pay for. Integrated care allows social and health care to work together in a joined up way that improves the outcomes for individuals and the experience for service users and professionals. Creating networks of providers that deliver care across professions will make it possible to deliver innovative person-centred models of care, based around multi-disciplinary teams. However, in order to realise our ambition for transformative integrated care, we will have to make radical changes holistically and at scale.
Each borough of North West London is already aware of the benefits of the integrated care model and has introduced various services that have improved the quality of care. The schemes that have been developed vary significantly in the populations they target, the design of the programme, and the stage of implementation. In general, the efforts so far have been small in scale and tackled the problem piecemeal, which is insufficient in the face of the challenges ahead.
However, people’s current experience of health and care services is often disjointed and fragmented. Each individual providing care may be doing a good job, but taken as a whole the individual and their family experience care that is poorly coordinated and confusing. Our objective must be to deliver better organised care at home which therefore avoids preventable emergency stays in hospital, or long-term dependency on institutional care.
Changing dynamics in North West London will shape the ways providers of care will need to respond to the needs of service users. Populations are ageing, increasing the number of individuals with long-term conditions. At the same time, the money available to fund health- and social-care is tightening. In addition, there is substantial variation in the level of care delivered at the moment. This is a problem because it creates inequity, but also because it suggests that some service providers are not delivering the levels of care to their service users that they ought to.
THERE ARE THREE REASONS TO PUSH FOR WHOLE SYSTEMS CHANGE
Commissioners and providers all want to do what is best for service users. However, the current system does not always allow commissioners and providers to make the changes required to meet the needs of service users. People who use services have to put up with three sources of frustration, which commissioners and providers will need to address through the three enablers of Whole Systems Integrated Care at the heart of our vision.
Reason 1. Service users feel disempowered in a reactive care system. People who use services are disempowered and on the receiving end of a reactive care system that focuses more on dealing with problems after they arise than prevention. This creates too many avoidable admissions, which are unpleasant for service users and expensive for the system. Our system is not geared up to help people to not need acute services in the first place.
This is why we must empower individuals to direct their own care, keeping them in their homes and local communities as much as possible.
Reason 2. Service user experience is confusing. Those with long-term or complex conditions must interact with health- and social-care services frequently, but they receive fragmented and varied care. There is a bewildering array of providers that do not appear to communicate to each other and it is not clear to service users who is in charge. People often have to repeat their story multiple times to different providers, which makes accessing care a frustrating experience. National Voices has published several ‘webs of care’, designed by service users or their organisations to illustrate these challenges (Please see http://www.nationalvoices.org.uk/webs-care).
The exhibit below shows how complicated care can be from a service user’s perspective. Malcolm had dementia, and saw over 15 different care professionals in order to get the care that he needed. Because he did not have a care coordinator, and because his care providers did not work in integrated teams, Malcolm's wife Barbara had to navigate his care without support. This was complicated and often left Barbara feeling frustrated with the care Malcolm received.
This is why we will need GPs to be at the centre of organising and coordinating people’s care.
Reason 3. Providers find it hard to work together. Health and care professionals are also frustrated with the barriers to collaborative working. There is little information flow between providers. The current funding and budget systems also make it hard to reallocate resources to where they are needed most.
This can also be prohibitive to collaborative working between different organisations. Frustratingly for providers, the payment system often rewards activity rather than outcomes.
This is why we must set up the system to help providers collaborate, and not to get in their way.
These three reasons for change lead to the three pillars of a more integrated system for the future. These pillars are that people will be empowered to direct their care, GPs will be at the centre of organising and coordinating care, and our systems will enable and not hinder the provision of care. The next section will outline how these pillars could be turned into a hopeful vision of care for the future.