Richard Vize: Integrate

Richard VizeIntegrating care across the NHS and social care holds the promise of giving patients a better service at the same time as cutting costs. But a study for the government of 16 integrated care pilots shows just how difficult it is to do. The dream of happier patients, greater productivity, and lower costs never materialised.

The evaluation of the pilots by Rand Corporation and Ernst & Young showed that after two years patient satisfaction was down, emergency admissions were up, and there was no clear evidence of cost savings despite falls in elective admissions and outpatient appointments.

Most of the pilots focused on integration between primary and secondary care. Few staff felt able to claim their patients had received a “seamless service,” and integration with social care was woeful. Staff complained about lack of training for new roles, and poor integration of patient records was a constant frustration.

Evidence of improved patient outcomes was patchy, but included a surge in the number of people diagnosed with dementia in Newquay, better treatment for COPD sufferers in Northumbria, and a sharp reduction in care home residents admitted to hospital to die in Cambridge.

The patients’ experiences hold important lessons for future attempts at integration. They felt less listened to and less involved in decisions about their care. What looks like better integration and lower cost to the NHS—getting a visit from a community nurse instead of seeing a GP or hospital consultant—may look like being fobbed off with a less qualified clinician to the patient; reduced access to the staff of their choice was one of the complaints.

This indicates that the discussions about integrated care happened over the heads of many patients, with too little effort being made to explain what was being offered to them and why it was a better option. It was a striking finding that while the staff felt communications improved within their own organisation and with other parts of the NHS, the patients experienced no such improvement. Some described professionals from different specialities disagreeing on treatment, while others felt they had not been given the right information about their condition. One patient described finding out from a leaflet that their condition was terminal.

It is possible the patient satisfaction scores underestimate the progress made. Many were interviewed at the beginning, which may have raised their expectations, and service improvement is not a smooth curve of uniform, ever-increasing user satisfaction. Mistakes will be made, new barriers to progress will emerge and systems will be slow to change.

A key finding is that there is nothing inevitable about attempts to integrate care leading to cost savings. It requires clinician time, management capacity, and investment. Change means agreeing clear goals, retraining staff, and developing the skill to negotiate across organisational boundaries. It is exceptionally difficult to try to overlay a new, joined-up approach on disjointed, dysfunctional systems. Simple objectives such as sharing patient information become immensely problematic.
The national tariff does not help the integrationist cause, because it focuses on episodic care and hospital activity.

The government has made a lot of noise about integrating care. Prime minister David Cameron has said health and social care must integrate, and the Health and Social Care Act puts duties on the NHS Commissioning Board, economic regulator Monitor, clinical commissioning groups, and health and well-being boards to promote it.

The integrated care pilots show how tough it is for the NHS to integrate with itself, never mind social care. The study does not undermine the case for integration—more effective use of resources and a better experience for patients—but it shows it is not a panacea.

Richard Vize is a  journalist and communications consultant specialising in health and local government. He wrote the report for the Commission on Dignity in Care for Older People and is writing the report for the King’s Fund Commission on Leadership to be published in May. He was the editor of the HSJ 2007-2010.