Policy responses and statements
- Name of organisation:
- Royal College of General Practitioners
- Name of policy document:
- Integration of Care Consultation Paper
- Deadline for response:
- 4 November 2011
Executive Summary:
At its most basic, integration consists of coordinated care across
different services and levels of care. It aims to place patients central
to the design and delivery of care and meet their needs through apparently
seamless, high quality and effective services.
The Royal College of General Practitioners (RCGP) has been a champion
of integrated care systems throughout its history. More recently the
College has developed the concept of Primary Care Federations and worked
with other Royal Colleges to develop models for integrating care across
health services.
There are already numerous examples in the UK and internationally
of how integrated care services can be developed. Some of the benefits
demonstrated include better patient experience and satisfaction with
services, improved clinical outcomes, and cost efficiencies.
These examples also highlight that there is no one definition of
integration, and that integration of care can take many forms. There
are also challenges to implementing integrative approaches to improve
care.
The RCGP wishes to consult on what integration means for general
practice and general practitioners (GPs) in order to develop a policy
that can guide decision making and service design. It has produced
a consultation paper which has raised a number of issues for general
practice and these issues are summarised below. In order to gather
views on integration, RCGP has posed a number of questions. The College
will also use the consultation feedback to respond to the Department
of Health established Future Forum, which is gathering views on integration
to provide further advice to the Department.
Issues for general practice:
1. In order to implement integration in general practice a shared understanding
and definition is essential.
2. Integrated care requires seamless transfer of patients and individuals
across a number of services. How this can be realised alongside competition
and choice of provider needs to be explored.
3. GPs are increasingly becoming involved in commissioning decisions
which includes the commissioning of integrated care services.
4. The role of commissioners to ensure that the needs of their population
are met means that commissioners need to be making the decisions as
to what integrated services are required and where. However in areas
where there are few providers or
where providers have a monopoly, the providers may be able to bring
undue influence as to what services are commissioned.
5. A system which incentives providers to increase activity and use
the most costly interventions to increase income is contrary to the
role of primary care to reduce the need for secondary care, manage
budgets, prevent and treat conditions early, and
provide services closer to home.
6. With the abolishment of Primary Care Trusts, leadership and management
capacity will need to be developed in other parts of the healthcare
system to lead on and facilitate joint working and the integration
of care services.
7. General practice may need to draw on specialist advice from providers
and other health care professionals to provide effective integrated
services, and the healthcare system needs to be able to support the
sharing of expertise.
8. If practice boundaries are abolished, as suggested by the Government,
the geographic spread of patients and their need to access services
remote from the GP could pose challenges to providing integrated services.
9. Joined up information systems and shared care records will facilitate
the sharing of information and joint working but requires investment
and sufficient data protection safeguards.
10. Performance and outcome measures should be aligned across different
care services to support, rather than hinder, the setting of shared
goals. There are still few NHS outcome measures available for monitoring
the effectiveness of services.
11. Reducing health inequalities and improving equity of care in
the new system is a guiding principle in the NHS. However the determinants
of health inequalities are often outside the scope of health services.
12. It is essential that integration does not lead to new barriers
between services, such as condition specific services, and silos of
care provision.
Comments on
Royal College of General Practitioners
Integration of Care Consultation
The Royal College of Physicians of Edinburgh (the College) welcomes the opportunity
to respond to the RCGP Integration of Care Consultation.
The College has the following answers and comments on the specific consultation
questions:
1. What in your
view are the three main benefits of integrated care? (p. 3)
-
The College considers that one of the key benefits of integrated care
is that the individual patient will be put at the centre of the healthcare
system rather than their diagnosis or disease. For example, a patient
may present with several different health problems and integrated care
should mean that they receive a much more holistic approach to their care,
in theory helping to address points such as support and care required after
an operation at an early point in the patient journey, therefore improving
the patient experience.
-
Another benefit of integration will be faster resolution of problems,
and faster diagnosis and treatment. This should be more cost effective than
the current system in the long term, as problems are identified earlier and
can be managed from the outset. Patients should not be sent inappropriately
to multiple secondary care clinics or accident units for "rule out" attendances
as more effective triage will take place.
-
Integration provides a good opportunity
for effective discharge planning as, for example, there will no longer be
artificial boundaries between health and social care and their relevant budgets.
2. What are the
risks of integrated care? (p. 3)
-
The risks of integrated care include a reduced standard of care if provided
by less well trained or experienced staff than currently provide the service. There
is a danger that a one size fits all approach could be adopted which does
not work for individuals.
-
There is some concern that integration could lead to poor clinical governance
and lack of clinical responsibility. There is not always effective communication
in the NHS between departments and between primary and secondary care. Integration
means this would have to be much better - can that be delivered?
-
There is a possibility of conflict of interest for GPs and other health
professionals where a financial incentive exists to provide a service in
the integrated system, and the necessary checks and reviews to ensure that
commissioning is appropriate could be prohibitive. The reconciliation
of competition and choice with integrating services could be challenging,
particularly in more remote and rural areas where little choice exists.
3. What definition of integrated care do you believe
should be used to inform policy decisions? (p. 1)
The College feels that the definition of integrated care must be broad and
incorporate both horizontal and vertical integration. The definitions
listed in the accompanying Consultation Paper by the WHO 1 and
Nuffield Trust2 provide
a sound basis to inform policy decisions.
4. How can competition and choice of provider be reconciled with integrated
care services? (p. 4)
This has the potential to be challenging as each clinical scenario has different
demands and requirements which may or may not be compatible with the idea of
increased competition for services. Improved patient outcomes must at
all times drive these proposals.
There will be increased pressure to manage budgets transparently as those
acting as integration coordinators may also be acting as providers of services,
and therefore again the interests of the patient must always be at the fore.
5. Who should make decisions about what integrated care services are
required in a given area? (p. 5)
Decisions need to be driven by local needs. A form of partnership committee
should be created in each given area, including experts from primary and secondary
care and other professions.
6. What role should providers take in developing integrated care services?
(p. 6)
Providers should take an open and active role.
7. How can models of payments be reformed to support integrated care?
(p. 6)
One possibility is a single payment to the commissioned integrated provider
network which is used to subcontract required services. However, the
payment would need to reflect local value and local population outcomes and
needs.
8. What leadership and management skills are required to develop integrated
care services? (p. 7)
Initially this requires high level involvement of commissioners and Trust
boards, including medical director or clinical service lead level.
9. What are the risks and opportunities of involving nurses, specialists
and Allied Health Professionals from providers in the commissioning of
integrated care? (p. 7)
There are potential problems for integration when there are different providers
of the different components, for example, GPs versus hospital based organisations,
both with their own budget pressures.
There will, however, be opportunities to ensure that the latest and most useful
interventions are supported by the commissioners.
10. What impact will the abolition of GP practice boundaries have
on the commissioning and provision of integrated care? How might these problems
be resolved? (p. 8)
No comment.
11. What do you need from information systems to support integrated
care, and how should they be funded? (p. 9)
The College feels there is a clear need to improve information systems across
the NHS, and particularly to progress the use of electronic records. Information
should be able to be shared with all providers in primary, secondary and community
care where appropriate with all the usual security safeguards.
Use of electronic records and improved information systems will develop at
different rates across the country, and funding needs to be locally adapted
to recognise local circumstances. It is unlikely this will be funded
at a national level in the short term following the report in August 2011 of
the Commons Public Accounts Committee on the National Programme for
IT in the NHS.
12. How might outcomes measures be used to support
integrated care? (p. 11)
There is a need to identify clear, measurable service quality indicators,
which should reflect the journey of care as well as clinical outcomes.
It is important to use indicators such as improved well-being, reduced hospitalisation,
improvements in independent living and local healthy longevity figures to measure
and assess the success of integrated care.
13. How can integrated care help to reduce health inequalities? (p.
11)
In theory, integration of care should help to address health inequalities. However
there is a risk that postcode inequalities may be exacerbated dependent on
local service configuration, as some areas may be much better served than others.
14. How can integrated care services prevent silo working? (p 12)
Silo working may be avoided by encouraging the involvement of generalists
and/or by auditing outcomes. Clinical governance is essential to identify
deficiencies in the service.
15. Are there any other important issues not identified above?
No. The College’s
main concerns are over the clinical governance of integrated care and that
the development of services is for financial rather than clinical reasons.
16. How can the RCGP help to ensure that integrated care services
are developed in the future?
The development of integrated care services requires close working between
the RCGP and the other medical Colleges, as well as relevant bodies and organisations
with an interest.
1 http://www.rcgp.org.uk/PDF/Integration%20of%20care_consultation%20paper_final.pdf,
p1
WHOsuggests that integrated care is ‘the organization and management
of health services so that people get the care they need, when they need
it, in ways that are user-friendly, achieve the desired results and provide
value for money.’
2 Ibid, p2
The Nuffield Trustdescribed the term as reflecting ‘a concern
to improve patient experience and achieve greater efficiency and value
from health delivery systems. The aim is to address fragmentation in patient
services, and enable better coordinated and more continuous care, frequently
for an ageing population which has increasing incidence of chronic disease.’
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[4 November 2011]
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