If integrated care is the answer, what is the question?

This is a question that we knew we had to answer in a clear and convincing manner when the Nuffield Trust and The King's Fund were asked by the Department of Health to contribute to the development of its strategy on integrated care. 

Our report of this work: Integrated care for patients and populations: Improving outcomes by working together, has now been published.

We are all too aware of the fact that 'integrated care' and 'integration' can sound rather dry and hollow as concepts, leaving most people puzzled that care could ever be intended to be anything other than integrated.

Indeed, what seems to have happened in recent years is that 'integrated care' has come to make complete sense to many health policy analysts and researchers, and in particular those who have spent time in the USA studying well-known integrated care systems such as Kaiser Permanente and Geisinger.

For others, it has been unclear as to what all the fuss is about, and at times, the conflation of 'integration' with 'anti-competition' or mergers has proved downright unhelpful in discussions about next steps for the NHS.

In our new report, we make it clear that the reason why integrated care is so important is that services for frail people with complex conditions are not always as they should be.  Numerous reports and commissions have highlighted the lack of dignity and compassion afforded to many (often elderly) frail patients in need of multiple services, and a lack of co-ordination of care is typically a feature of such analyses.

Furthermore, the NHS spends too much time and resource reacting to health care crises, rather than investing in systematic prevention work or proactive care of people at risk of falling ill. We conclude that this whole area of non-elective care has somehow not been as critically important within NHS policy and management as its elective (waiting list-based) cousin.

Given the focus on improving access to NHS care in the early 2000s, and the need to tackle unacceptably long waiting lists, it is perhaps understandable that non-elective care slipped off the management radar, but there is now an urgent need to redress the balance.

In our report, we use the words of National Voices (2011) to point out that: 'achieving integrated care would be the biggest contribution that health and social care services could make to improving quality and safety.'

Our own case for integrated care is set out as follows: 'care for people with complex health and social care needs must be made a real and pressing priority for commissioners and providers as this will be the key to assuring people of high quality care and making the health and social care system more sustainable.'

A further concern for us in this work was to move beyond analysis of the 'integrated care problem' (and both the Nuffield Trust and the King's Fund have published widely on this topic, now brought together in a concise slidepack and suggest the practical steps that can be taken to start making integrated care a reality for the frail and vulnerable patients who most need it.

We suggest that there are three main priorities for policy makers. First, to set a clear, ambitious and measurable goal to improve the experience of patients, service users and their carers, and for this goal to be as significant for managers and clinicians as were waiting time targets in the 2000s.

Second, we suggest that patients with complex needs be guaranteed an entitlement to an agreed care plan, a named case manager responsible for co-ordinating their care, access to telehealth and telecare, and a personal health budget where appropriate.

Finally, we argue that integrated care needs to be introduced at pace and scale, with a strong commitment to evaluate different approaches in a systematic and robust manner, and over a minimum of five years.

To return to the question I set myself at the outset, if integrated care is the answer, the question is: why does the NHS seem to keep failing frail older people with complex needs, and how can we make this a 'must do' priority?