I was in Glasgow earlier this month speaking at a British Geriatrics Society (Scotland) symposium about community services for older people. Two things struck me: first, how refreshing it was to be at a conference where England’s Health and Social Care Bill was barely mentioned; and secondly the abundance of practical examples of health care integration from across Scotland.
One of the major criticisms of the Health and Social Care Bill was that its emphasis on promoting competition between health care providers risked stifling efforts by clinicians in England to provide more seamless, integrated services for their patients. The Government’s response to the NHS Future Forum’s recommendations suggests that these criticisms have been taken on board, and that integration and collaboration will now be more actively encouraged in the English NHS.
So, an interesting litmus test is whether the following examples, which I heard about at the conference in Glasgow, will have parallels south of the border.
- In many areas of NHS Highland, each GP is being linked to a named geriatrician. In these areas, Highland GPs now have a dedicated specialist they can contact to discuss an older person’s care and, equally, Highland geriatricians now have a defined population of older people in whom they should take a proactive interest. In these parts of Highland, GPs and their named geriatrician meet regularly to discuss complex patients; they schedule clinics at the same time in the same building to encourage interaction; and they hold joint educational sessions. As Dr. Martin Wilson, a consultant geriatrician in Inverness, put it, “I feel I'm training them but it's just as likely they're training me.”
- In NHS Lanarkshire, a new system is being piloted where all emergency admissions are routed through a single telephone number. The referring GP is asked whether instead of an ambulance they would prefer a geriatrician to review the patient at home within the hour. As part of this pilot scheme, the acute care geriatrician can then draw on a range of rapid-access diagnostic, community and social care services that are all designed to help avoid the need for a hospital admission.
- In NHS Grampian, as in Highland, each geriatrician is aligned to a group of GP practices. Geriatricians conduct regular joint domiciliary reviews for all patients living in care homes, and they have responsibility for providing geriatrics education to his or her linked GP colleagues.
- Finally, in Angus all older patients admitted to Ninewells teaching hospital have a multidisciplinary team assessment within 24 hours of admission, and suitable patients are then transferred to a 48-hour ward, which sounds similar to Kaiser Permanente’s 23-hour ward. As a result of this time pressure, the majority of older patients are discharged from Ninewells within 72 hours often to a network of linked community hospitals. Staff at the teaching hospital, the community hospitals and in the community all use the same documentation. Local geriatricians also hold “polypharmacy clinics” at their linked GP practices, where they review any patient aged 75 or older who is taking 12 or more medications. As Dr Douglas Lowdon explained, “I now prescribe like my GPs do, and they prescribe like I do”.
In any health care system, a large proportion of costs are attributable to older patients with complex needs. Such people typically require an intricate web of services spanning primary care, secondary care, community care and social care. As a result of this complexity, these patients face the double hazards of:
(a) Duplication (where two providers deliver the same care, or a patient is asked for the same information repeatedly); and
(b) Falling through the “gaps” (where one provider mistakenly assumes that another provider is delivering specific care).
The examples of integration from Scotland seem well placed to address both these problems simultaneously. By breaking down unnecessary barriers between GPs and geriatricians they may be able to improve the quality of care for older people and at the same time reduce overall costs. Clearly this is a tantalising prospect but the challenge now will be to demonstrate these improved outcomes with careful comparison to an appropriate control group.
Lewis G (2011) ‘Integration in Scotland: a litmus test for the NHS in England?’. Nuffield Trust comment, 24 June 2011. https://www.nuffieldtrust.org.uk/news-item/integration-in-scotland-a-litmus-test-for-the-nhs-in-england