Integrated care: a story of hard won successBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3529 (Published 31 May 2012) Cite this as: BMJ 2012;344:e3529
The same patient was admitted to an emergency department 19 times in six months with hypoglycaemia, but no one ever told his diabetes consultant in the same hospital. The North West London integrated care pilot is working to ensure that never happens again.
The pilot was launched in 2011 to meet the needs of people with diabetes and those aged over 75. It brings together primary care, community services, acute care, social care, and mental health.
It was set up because local hospital trusts needed to reduce pressure on beds and respond to the funding cap that the tariff system now imposes on emergency admissions, while commissioners wanted to raise quality while cutting costs as part of their response to NHS budget constraints.
So far 93 general practices serving more than 500 000 patients have signed contracts with the pilot, along with four hospitals, three community providers, and five council social care departments. The partners are organised into 10 multidisciplinary groups spread across northwest London.
The aims are to cut hospital use, including non-elective medical admissions, by 30% over five years and nursing home admissions by a tenth, while reducing the £620m (€770m; $980m) annual cost of services for diabetic and older patients by 24% over five years. The savings in non-elective admissions alone—cutting these by 30% equates to roughly one fewer admission per GP per month—are expected to release £10-12m a year for reinvestment. Early results are promising. Between July 2011 and January 2012 the number of non-elective medical admissions among the 28 000 patients aged 75 and over fell 6.6% compared with the same period in 2010-11. Admissions for such patients at practices in northwest London boroughs not covered by the pilot rose 6.5%. Comparing the two figures the pilot estimates it helped its patients avoid 304 admissions.
Diabetes was chosen because there are good services at Imperial College Healthcare NHS Trust, while it was obvious that integrating care for over 75s should raise quality and cut costs. Lessons learnt from these two groups will be used to extend integrated care to other population groups and diseases
Clinicians have designed standardised care pathways, and they are now working to agree care plans for every diabetic patient and at least half of patients over 75. The governance structure gives all organisations a voice, and information is shared through case conferences and an information and risk analysis system working across health and social care. Providers and commissioners share the savings.
The experiences of Gerard Burns, who has type 1 diabetes and several other conditions, show why the existing system has to be overhauled. When he ended up in intensive care after an operation to fit a cardiac stent, the cardiac team knew nothing about how his diabetes was being managed, even though it was in the same hospital.
He finds emergency departments particularly frustrating: “They are starting from scratch; they know nothing [about me]. It would be great if these guys could access the information because it saves time, gives them more confidence, and makes me feel safer.”
During the pilot’s planning phase Diabetes UK and Age UK helped develop the care pathways, challenging the GPs, community nurses, consultants, and others about the care they delivered. The clinicians were so impressed with this contribution from the service users’ perspective that they now have patient representation on the board and a strong user voice throughout the structure, such as helping determine education and training needs.
Patient involvement in establishing an integrated care service is essential because clinical staff do not know how the whole system works—the only person who crosses those organisational boundaries is the patient. During the pilot’s development a theme emerged of patients having to endlessly repeat the same story about their condition, tests being duplicated, time being wasted, and clinicians and patients being unsure if treatment was appropriate or safe.
Launching the pilot to address these failures involved getting the money, legal framework, and information technology backbone in place, then getting the clinicians on board. The funding—about £5.7m start-up costs including lawyers’ fees, expected to reduce to annual running costs of around £3.5m—largely comes from recycling money saved through the reduction in unplanned admissions. The money flows show one of the obstacles to integrating care—NHS finances are not aligned to facilitate it. The pilot has been ingenious in using a Heath Robinson financial machine to power it, but it should not need to be that complicated.
But the hardest part was getting the clinicians to sign up. General practitioner and pilot codirector Aumran Tahir says there was resistance from GPs worried about “takeover” by the hospitals, while fellow codirector Andrew Steeden, medical director of NHS North West London, believes “almost everyone has come to the pilot with a degree of scepticism, animosity, and hostility because everyone feels challenged.”
To bring people together on equal terms an external chair was needed. Former London Deanery director Elisabeth Paice accepted the role. The first three meetings of the management board were difficult. “People were saying things such as ‘please don’t take the fact that I am here as any indication that I or my colleagues have any intention of being part of what you’re planning.’ There was quite an atmosphere,” she says.
Tahir explains how much suspicion and misunderstanding there was: “I remember working with [diabetes consultant] David Gable early on—David was the enemy at the time. We thought ‘we don’t want to refer to David because he is trying to admit every patient to his trust.’ That is the way the NHS has incentivised me—to work individually. When we got into a room together we realised David, of course, does care about patients. By the second or third time you meet you start to relate to people, break down barriers, and find common interests. The common thing here was that everyone wanted to improve things for patients.”
Numbers attending the meetings grew from the initial 30 to almost 70 on one occasion, with a strong commitment from GPs, consultants, and chief executives. Gradually a culture of respect and cooperation developed.
Paice recalls: “This was a revelation. I remember it became clear the community pharmacist was a highly respected member of the group. As a consultant I had never even met a community pharmacist.”
The pilot began to work because clinicians were leading and were focused on patients, while the managers and money were there in support. Although cutting costs is an objective, the project is not financially and managerially driven. As operations director Scott Hamilton puts it: “The pilot was handed over to clinicians and we said ‘you design it how you want it and we will make sure it works for you in the background.’”
Chief executives and other senior managers bought into the pilot early on. This gave clinicians licence to give it their time. Steeden says: “Clinicians have to feel supported by their managers. In the past we have been asked to do innovations and people just haven’t felt supported, so in six months people have backed out and it’s just wasted their time. But once everyone realised this was going to last we were able to give up our suspicion of it and buy in.”
To involve GPs, an honest conversation about money was needed. “Integrated care must be adequately funded—not rewarded as such, but GPs have to be recompensed for what they are putting in,” Tahir says.
Integration does not mean merging the services. It is about integrating the experience for the patient by filling in the gaps, so staff in the emergency department can see the care plan and alert the GP, the pharmacist knows what the consultant has agreed with the patient, and so on.
What fires up the doctors is the chance to exchange ideas on care with other clinicians. Compared with the suspicion and failure to collaborate that preceded the pilot, Tahir feels it is “like I’m going back to medical school—it is much more enjoyable and friendly.”
Gable gives a powerful example of how he has changed his own practice as a result of the relationships he has developed. Many diabetes patients suffer depression, yet Gable admitted he had not met a consultant psychiatrist in his present job until a year ago.
“Sitting down and discussing patients with people from mental health I have found phenomenally useful. It has changed the way I think about chronic disease. A long term condition such as diabetes has more similarities with some of the models in mental health than the acute medical model . . . a lot of what we do is behaviour change,” he says.
The pilot has meant “an entirely different way of working for GPs,” admits Tahir. “It means doing things in a much more structured and systematic way. I have patients in well before they get ill, hopefully, and agree a care plan based on our risk analysis tool. You have care planning at medical school, but it gets beaten out of you in the first two years of practice. Now it is coming back. To do that system process change is actually extraordinarily challenging.”
The headline success so far has been the 6.6% reduction in emergency admissions. Other benefits include GPs gaining a better understanding of diabetes treatment, increased coordination with social care, and fewer outpatient referrals.
Plans to extend the service include signing up more GPs, including some in singlehanded practices who feel they cannot afford the time. It will also be expanded to chronic obstructive pulmonary disease and coronary heart disease. NHS London hopes to establish around a dozen similar pilots in the coming months.
Key to success
Gable’s advice to clinicians considering setting up an integrated care scheme is to “just do it—clinicians have to get themselves together and get on with it.”
Steeden agrees but stresses, “It is not an easy journey. It is tough and you are going to hit opposition from everyone.” Hamilton says, “You need a tough skinned team.”
But the success of the northwest London pilot exposes underlying weaknesses in the NHS. It should not require lawyers to draw up agreements to get clinicians to work together. Nor should it require what Hamilton describes as “smoke and mirrors” to fund it. The IT backbone to the pilot is a reminder that when billions of people can share information globally the NHS can still not routinely share information between hospital departments, let alone across the health and social care system. There is a risk that integrated care schemes will use IT systems which will be unable to integrate with each other.
But the biggest obstacles to integrated care are cultural—creating a health service where teamwork is the norm and silo working is unacceptable.
“You need communication skills,” Paice says. “It is not how well you communicate—communicating at all would be a nice start. So when you have someone on an emergency department trolley rambling and confused, to know that that person had been living on their own fit and well is hugely important. With the IT tool everyone is logged into the same information.”
She believes that integrated care, with its emphasis on planning, prevention, outcomes and sharing clinical data, encourages clinicians to look beyond individual patients to address population health.
“Some of your working week needs to be spent looking at the overall performance of your practice or unit, using metrics to drive improvement and benchmark performance. It is the hallmark of excellence in medicine.”
Cite this as: BMJ 2012;344:e3529
Competing interests: The author has completed the ICMJE unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.