Integration is a system-wide improvement which often happens across multiple services and organisations. The RCP’s Future Hospital Programme promoted a comprehensive model of care which brings specialist care close to the patient. Integration of services is core to this and is an ambition reflected in wider UK health policy such as the Five year forward view.
The need for integration of care across different settings may be prompted by:
Patients: Individual patients and patient organisations may highlight fragmented care to care providers. A piecemeal approach to care can compromise health outcomes and reduce satisfaction regarding interaction with health professionals.
Primary care: Staff may be looking for better solutions in managing a growing number of patients with long-term conditions.
Secondary care: Specialists may find that problems communicating with other services or patients challenge their ability to provide safe, timely, whole-person and continuous care for patients. Senior leaders may also view it as a solution to meeting targets and reducing outpatient referrals.
External agencies: Service reviews or independent investigations by external organisations such as the Care Quality Commission or local health watch.
In Oxfordshire, the need for integration arose from a number of factors observed in our everyday practice, including:
inappropriate timeliness of referrals to secondary care
frustration with the lack of information when seeing a patient
unawareness of patients who could benefit from specialist care
a desire to share expertise across primary and secondary care in order to manage the whole population more effectively.
All of these factors had an impact on patient care and experience, our effectiveness as clinicians, and the overall performance of the service. One way of addressing these issues would have been to stop accepting referrals, which (with additional professional education and appropriate governance) may have been seen in the community, but this would not have addressed the real problem, which is that information flow and communication between services is incomplete and too slow.
My responsibility as a consultant in diabetes and acute general medicine is to provide care to patients who need specialist input, whether they are treated in a community or in a hospital. In the acute general medicine setting, I too often see patients suffering from complications from diabetes. In outpatient clinics, I meet with a variety of patients who make me question if the system works properly.
I treat patients who could be seen in the community if there was adequate support.
I see patients whose referrals have been delayed, compromising their health.
I hear complaints from patients who have been waiting too long for specialist input.
I am aware of patients not engaging with either primary or secondary care.
When I support patients in primary care, whether by providing advice to primary care staff or by seeing patients in community diabetes clinics, I am aware that I am only helping a small group of patients referred by GPs who are proactive.
This cannot be a sustainable or equitable service which will deliver the best care for individual patients or the population as a whole. It is these experiences which lead clinicians to strive to develop more integrated services.