Recently, on one of my clinical general practice days, I made 21 phone calls to a London hospital trying to leave a message asking a consultant to call me urgently. A patient I had seen at 9am had decided not to have a disfiguring operation for a cancer that was planned for 10 days later.
I needed urgent advice about the options for reconstructive surgery so that I could have an informed discussion with her during the following week about the choice she had made. Had she understood the facts about her condition? The consequences of refusing treatment? Time was of the essence: I urgently needed information from the surgeon who had assessed her.
I started at 10am on that Friday morning, feeling confident. Armed with a helpful list of possible contacts – and phone extensions for each of them – from the multi-disciplinary review letter in my patient’s notes, I began.
Seven calls, seven answer phones. Then, someone answered – a nice secretary, but the wrong department. Back to the drawing board. Ok, how about departmental manager – maybe she could get a message to the consultant? She was on leave. And so was her deputy.
As a GP on the edge of a complex cluster of health care providers, I need to be confident that I can reliably communicate with other parts of the system
By this point, it had become a personal challenge to get my message to the surgeon (or his PA) before the weekend. I tried the hospital switchboard: “surgical services, please” I said. I got put through to paediatrics. A nice woman, sensing perhaps a note of despair in my voice, said she would do the chasing for me and promised to call me back with the name of somebody who could help me.
Time passed. I tried the Chief Executive. Perhaps someone in their office just might have an organisational chart to guide me, I thought. Three calls: answer phone each time.
By then, (3.30pm) a meeting was looming (I have a job, remember). I tried again, was cut off four times (could have been my mobile at fault there) and finally spoke to a very senior manager who was extremely helpful.
By 4.45pm my phone was buzzing like crazy with calls from all kinds of hospital managers and at 5.30pm I had exactly the conversation that I needed with the surgeon. I was now, finally, prepared for discussion with my patient. Thank goodness for stamina...
Why all the phone calls? Would an integrated IT system have sorted me out through the use of secure e-mails? Probably not. In this case, where time was of the essence: I needed to trust the whole system. To know that somebody would pick up and respond to the message on Monday; that I would find out quickly if the surgeon was away on leave; that somebody else would contact me if necessary. Personal communication is still necessary at times.
I have spent years writing reports about integrated systems in which the aim is for multiple providers to work together in an efficient, co-ordinated way, focused on patient needs. I have championed the need for integrated IT; shared clinical pathways; aligned financial incentives; robust governance and reporting arrangements etc.
But when push comes to shove you can't get away from the need for reliability and trust that complex systems will work well. In his book High Velocity Organisations, Steven Spear argues that it is the behaviours of leaders and workers within successful, complex organisations that underlies their success.
He describes how they invest effort into developing systems and processes to ensure that all the different parts of the organisation work together in a standardised and reliable way. But these organisations have another ingredient. They ensure that everybody's daily work includes generating insights into how to work better and more effectively together.
As a GP on the edge of a complex cluster of health care providers, I need to be confident that I can reliably communicate with other parts of the system. When things aren't working well, I need to be able to highlight the problems and help shape the response.
A large and influential group of health experts argue that integration between providers (and, in some cases, between payers and providers) is crucial for transforming many areas of health care to drive quality and efficiency.
The hunt is on for how to achieve these changes, and options for contracting for integration are a current vogue through initiatives such as COBIC, prime and alliance contracting. After my 21 phone calls I started to wonder whether these innovative approaches to commissioning really could succeed in stimulating the detailed changes in systems, processes and behaviours needed to deliver reliable, high quality health care.
Contracts for integrated services with clearly specified outcomes and aligned financial incentives will no doubt create a context in which participating providers will have incentives to improve care. But we are taking a huge leap of faith in assuming that they will stimulate change in the detailed, day to day, nitty gritty interactions between professionals Stephen Spear describes in high velocity organisations.
We have yet to discover whether a family practice network holding a capitated budget could achieve this kind of change. Or, whether a prime contract held by an acute trust, an integrator organisation or a third sector organisation would do better. We have a lot more learning to do before we can confidently advocate the merits of one of these approaches over any other.
In Greenwich, where I work as a GP, our integrated care pioneer work has no shared IT (though a new system is in development), no aligned budget (the Better Care Fund is coming) and no prime contract. A collective commitment across local government, community health providers and clinical commissioning groups to simplifying, co-ordinating and improving care is what is driving progress. Jointly recognising and solving problems lies at the heart of what we do.
Rosen R (2014) ‘The nitty gritty detail of integrating complex systems’. Nuffield Trust comment, 17 April 2014. https://www.nuffieldtrust.org.uk/news-item/the-nitty-gritty-detail-of-integrating-complex-systems