Integrated care is what we all want

Integrated care is one of those concepts that’s hard to argue against. Who among us would not want hospital staff to work closely with primary, community, and social care services, so that, when we turn up in the emergency department with a serious exacerbation of our chronic condition, the team there knows all about us? Better still, wouldn’t we all want the various teams to liaise closely so we don’t have to go to hospital at all? If, by integrated care, we mean seamless, high quality care, it’s obviously desirable. So why is it so hard to achieve? And why do we struggle to deliver it in the National Health Service—arguably the one health system in the world that should be able to provide seamless care?

There’s no shortage of stories about failed and fragmented care in the UK and elsewhere. But this week we present a success story, hard won against every kind of obstacle, and all the more instructive for that. As Richard Vize reports, a pilot scheme in North West London set out to reduce pressure on hospital beds and has ended up saving money and improving quality of care. It has also conjured better communication and understanding among clinicians in unexpected ways (doi:10.1136/bmj.e3529).

But back to the barriers. No one who is planning to set up an integrated care scheme should underestimate them. “It is not an easy journey,” warns Andrew Steedon, who co-directed the project. “It is tough and you are going to hit opposition from everyone. You need a tough skinned team.” Sceptical, suspicious, unwilling, and obstructive clinical colleagues seem to have been the main opposition. But in the end it was clinicians who led the scheme. Still it wouldn’t have worked if clever and committed people hadn’t found a way round the NHS’s complex financial mechanisms and disparate information technology, none of which is aligned for integrated care. Vize describes a “Heath Robinson” financial machine and rightly says, “it shouldn’t have to be so complicated.”

As for designing better pathways of care, it turns out that the only people who know how the whole system works are the patients. Their input transformed the North West London scheme and became, like integrated care itself, obvious. Only they cross the organisational boundaries, a fact that underlines the wisdom and importance of efforts to give patients control of their own medical records (http://www.patientsknowbest.com/).

This story suggests that the best way to achieve efficiencies while improving the quality of care is collaboration not competition. Meanwhile, much of the discussion about the latest round of changes to the NHS in England has focused on whether competition will be good or bad for health (BMJ 2011;343:d4136, d4205).

Can this approach work more widely? Buoyed up by their success, the North West London team is looking to expand into other age groups and diseases. The much lauded integrated care scheme in Torbay (BMJ 2011;342:d1917), however, is said to be struggling to sustain itself (www.hsj.co.uk/hsj-local/south-west/trust-rips-up-ft-plans-and-seeks-merger/5045421.article?blocktitle=Latest-Health-Service-News&contentID=113). At the moment, such transformational schemes rely on the exceptional efforts of exceptional people. Our challenge now is to make the exception the rule.