Walking up from the station, the Royal Berkshire Foundation Trust has a rather grand frontage. David Oliver, the consultant geriatrician who organised my day, guided me, by phone, round to the modern entrance and bought me a coffee. It was shortly before 8am and, on the hour, we dived into the maelstrom of the clinical decision unit. Over the next two hours I would watch and listen as a team of professionals tackled the problems posed by 17 elderly patients who had been admitted overnight. Only two patients were below the age of 80 and the first person we saw had cancer, heart disease, diabetes, anaemia, falls, and no help at home.

When I started doing ward rounds, more than 30 years ago, they were formalised processions of white coats considering each patient in a ritualised manner. This round felt more like the frenzy of activity you see from a Formula One pit crew. Each and every person in the multidisciplinary team contributed: nurses, occupational therapist, physio, patient co-ordinator, and junior doctors. There was no procession. People peeled off to sort investigations, do assessments, and initiate liaison with community services. Frankly, it was a privilege to see the absolute dedication, hard work, and tenderness the team showed. Before I left the hospital more than a third of the patients seen had been discharged.

The next team I met was the liaison psychiatry team. They are hosted by the trust, but work for the community. They have reduced falls, increased safety, improved antipsychotic medication, and decreased readmissions. They have trained 1000 staff, including security, in dementia awareness. They take referrals from all professionals. It struck me that if we really get the message about value (quality and cost) embedded in the way we think about commissioning and provision, then teams like this will be essential.

Equally invigorating was to meet with GP leaders from a small, but energetic, clinical commissioning group (CCG) that is working in collaboration with other CCGs to make real the concept of clinical leadership in commissioning and bring some innovative thinking to aligning incentives. They even bought me lunch—thank you!

Last, but by no means least, I spent some time with the Reading intermediate care service. They have created an integrated team by co-locating health and social care staff.  They emphasised how powerful this was as it strengthens relationships, communication, and wraps services around the patient.  This was echoed by the acute trust clinicians who found it the easiest service to work with.

At the end of the day as I walked back to the station I reflected on the messages I had heard.

There were four big themes—the need for:

• Accessible, proactive primary care.
• Integration—to optimise out of hospital care.
• As much focus on discharge from the hospital as is given to four hour waits.
• Continuity of information.

Each and everyone of those is something that NHS England is seeking to support. It will take time and it isn’t a quick fix, but the people, the will, and the determination is there.

Martin McShane is the director for Domain 2 of the outcomes framework for NHS England. This role is focussed on enhancing the quality of life for people with long term conditions and supporting the other Domains. Qualifying in 1981 he undertook training in general and vascular surgery before electing to work in General Practice. From 2004 he has been immersed in commissioning, working for PCTs, specialised commissioning and regional networks. He was a member of the National Patient Safety Forum.