What do we mean by ‘integrated care’ – and how can we test its integrity?
Policy bite by Amanda Howe
‘Integration’ has become the latest buzzword on the health policy agenda – WHOi
, the King’s Fundii
, and the Nuffield Trustiii
all have major programmes of work on this topic, and in the UK the pre-election political party manifestos are awash with the need for ‘integrated’ care. But there are many definitions and models being debated, and these tend to depend on the nature of the health system and the level of integration envisaged.
For example, the UK RCGP has used the ‘horizontal integration’ definition of ‘Patient-centred, primary care led, delivered by multi-professional teams, where each profession retains their professional autonomy but works across professional and organisational boundaries to deliver the best possible health outcomes' iv
, but the USA model of an integrated care organisation defines itself as “a formal or virtual vertically integrated organisation from primary to acute service levels, often serving a defined population”. The differences may be profound, with family medicine working to a hospital provider, rather than across a community – but the main thing is whether the integration of care works for patients. Our UK member organisation, the Royal College of General Practitioners, has recently published ‘Five tests of integration’ in a manifesto to go to all political partiesv
. These tests help us to know whether the integration is primary care – oriented: they say that,
“Proposed models of integrated care should:
(1). Ensure community-based services are led by community-based clinicians with a person-centred perspective.
(2). Underpin safe patient care by ensuring that GPs [family physicians] can continue to act as independent advocates for their patients - with their emphasis on the person not the institution.
(3). Avoid over-medicalization and the perpetuation of clinical treatments that are over-reliant on the perspective of condition-specific specialists.
Proposed models of integrated care must not:
(4). Lead to major top down structural reorganisation, which would lead to the setting up of new bureaucratic structures and divert millions of pounds away from patient care.
(5). Lead to the diversion of NHS funding to plug the social care gap." (This is about residential care of older dependent people – a concern that health service funding will be ‘lost’ ).
This may seem very abstract and high – level when you are seeing your fortieth patient in an overcrowded clinic, and the electric power has just gone off. But every day leaders of family medicine are having to discuss service delivery in their locality, or region or nation – and are trying to make a difference to the choices made by policymakers, who will be more conscious of the big corporate models than the community-oriented ones. An affordable service which brings good comprehensive care close to home, and where different parts of the clinical and social support team can liaise to make the best of their contact time with patients, will be both cost-effective and popular. A patient who has to make multiple visits to different clinics and different hospitals (costly in time and money) for the different bits of their body and mind will either not attend or become exhausted and confused in the process – as will their friends and family.
So when you find someone in your network is talking about ‘integrated care’ – make the tests, and talk up horizontal integration – you will have WHO policy and WONCA to back you up!
vi All downloaded 27/9/14.