My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Patient-centred coordinated care

Filed Under (Integration, Patient Choice, Patient involvement) by Paul on 18-03-2014

Over the last year I have read more about integrated care than about any other health and social care topic, and even though I don’t read much more than 5% of what is published on the topic we are talking about what, in hard copy days, would have been called “forests of paper”. I am sure that in the digital world, there are several terabytes of disks filled with the stuff.

Over the next few days I want to make some comments about what has and has not been achieved in this area of health and social care in the past year, but first some comments about language.

Because so much has been written about integrated care, I want to say a few words about the language we use to describe the changes we want to bring about.

Quite rightly much is made in making the case for change for integrated care, of the bad patient experience created by the current model of fragmented care. Different specialists feeling they are the only doctor the patient sees; different nurses asking for the same back story to be outlined by the patient; different social care staff coming at different times to carry out un-coordinated care. At best it’s merely bewildering, at worse it has a bad effect on patient well-being.

Nearly every local case for change in integrated care talks about patient experience as a reason for change before resources are ever mentioned.

Given the recognised saliency of patient need in this set of changes, it’s a great pity that the language we use to describe what we are doing is still a language dominated by our task and not by language that patients can understand.

About a year ago NHS England commissioned National Voices to carry out a discussion with patients to find out how they and their carers describe the changes that we call “integrated care”.

The very fact that NHS England asked for this to be carried out was a recognition that the current method of description and explanation needed change. Commissioning the work was a good thing. But if you trawl through NHS England’s web site you will see that the changes are still referred to as “integrated care”. They paid for a patient centred piece of work to be carried out and then ignored it in their own practice.

What did National Voices actually come up with? (Here’s the link to a presentation)

After extensive discussion they found that the phrase that made sense to the public was “person-centred coordinated care”.

Integration is what the system needs to do.

Coordination is what the public need to experience.

The key wish for patients is that,

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”

Contained in this sentence is the reason why language is so very important and why who is in charge of the language is such an issue of power over practice.

This sentence is reasonable. But it’s pretty obvious that it describes a way of developing care which puts patients in charge.

It starts off with I can plan my own care. Whilst this is ideologically what the NHS and social care claim to want, it fairly obviously implies that organisations that currently plan patient care around their needs would no longer be in charge.

With people who work together to understand me and my carer. Again ideologically it’s what everyone says they want – of course we work together to understand the patient and their carer! (Well no, that’s the problem isn’t it?)

Allow me control… Again the wish is that patients should have control, but the reality is that services are not organised around that concept.

…and bring together services to achieve the outcomes important to me. The clinching argument here is that the services would have to be organised around outcomes that are “important to me”.

So what National Voices have wisely done is to ask patients how services would be different if they were organised in their interests.

Unsurprisingly that resulted in not only a shift in language but a shift in the power that language describes.

And that’s the reason, a year later, we all go on talking about “integrated care” and not using the language that patients want to use to describe that change.

This is the rather sad conclusion. Even when the NHS genuinely wants to do something that is in the interests of patients and even when we explicitly find out how patients want to describe these changes we still can’t bring ourselves to put it into practice.

Our own language, our ability to talk to ourselves internally is much more important to us than our ability to communicate with patients.

And the reason for that is that we know once we start using the language of patients to describe what we should be doing, we will cede a lot of the power that we have over their lives to them.

The development of integrated services for patients may be being adversely affected by the passion that many feel for the forces that fragment NHS care.

Filed Under (Health Improvement, Integration) by Paul on 07-01-2013

2012 was the year when every part of the NHS that came under the powers of the new Health and Social Care Act had the duty to integrate services added to their statutory powers. In addition to the deluge of instructions to integrate, November’s mandate from the Secretary of State to the National Commissioning Board made it clear that he wanted the public’s money spent on the development of integrated services for NHS patients. Read the rest of this entry »

Another New Venture

Filed Under (Health Improvement, Healthcare delivery, Integration) by Paul on 22-11-2012

Regular readers of my blog will recall that I have been saying for some time that the NHS is going to need some help from beyond its culture. This is specifically the case when it is developing something that is both as new and as difficult as integrated care for NHS patients.  I have written a few times about the need for organisations to specifically act as integrators bringing very different providers together to create a patient pathway.

From today I, and a few others, are setting up a company called LTC Ltd. as one of these integrators. Our aim is to help develop integrated care for NHS patients. The company, and myself as a part of it, will be bidding for work from NHS commissioners.

I wanted to make my part in this new venture public at the earliest opportunity.

The web site should be up later today at www.longtermconditionsltd.co.uk

How might last week’s mandate from the Secretary of State impact upon the NHS over the next few years? How can it make integrated care a reality?

Filed Under (Clinical Commissioning Groups, Integration, National Commissioning Board) by Paul on 19-11-2012

One of the main consequences of last year’s pause in the passage of the Health and Social Care Bill was a blizzard of amendments to the statutory duties of every single NHS organisation. Amongst the many contradictions that arose from these amendments, there was one constant. By the time it became an Act, after the Bill was amended and re-amended in the Lords every single possible organisation had had a duty to create integrated care laid upon it.

Last week’s mandate for the NCB from the Secretary of State has begun to put some flesh on the bones of how it will be expected to carry this out,

2.1 We want to empower and support the increasing number of people living with long term conditions. One in three people are living with at least one chronic disease. By 2018 nearly 3 million people, mainly older people, will have three or more conditions all at once

2.7 As a leader of the health system, the NHS Commissioning Board is uniquely placed to co ordinate a major drive for better integration of care across different services, to enable local implementation at scale and with pave from April 2013

2.8 The focus should be on what we are achieving for individuals rather than for organisations- in other words care that feels more joined up to the users of services with the aim of maintaining their health and well being and preventing their condition deteriorating as far as possible. We want to see improvements in the way that care

  • Is coordinated around the needs, conveniences and choices of patients, their carers and families- rather than the interests of the organisations that provide care
  • Centres on the person as a whole rather than on specific conditions
  • Ensure people experience smooth transitions between care settings and organisations including between primary and secondary care, mental and physical health services, children’s and adult services and healthy and social care- thereby to reduce health inequalities
  • Empowers service users so that they are better equipped to manage their own care as far as they want and are able to.

The NCB will quite rightly pass many of the main ways to implement this mandate onto CCGs. I will explore in a later post what that might mean.

But the NCB is not only a performance manager of CCGs it is also commissions health care itself.

The NCB commissions £12 billion of specialist health care. If it takes the Secretary of State’s mandate seriously we would expect to see this enormous buying power used to ensure that the services that it buys bought from specialised providers would be part of an integrated care pathway.

This will not be easy (but NOTHING about creating integrated care in the NHS will be easy) because most specialist commissioning is a specific episode of care. However specialist episodes of care, like all other care, need to be part of a pathway of care. The NCB will have to put these episodes alongside the care before, and especially after, the specialist episode to turn it into a pathway. This will be difficult because care on both sides of specialist episodes will be commissioned by local commissioners (CCG and local authority).

But if the NCB wants to demonstrate how it is carrying out its mandate it will have to make this happen.

However there is a much more direct impact that the NCB has through the £20+ billion of GP services that they buy. (One of the odder aspects of this localising reform was the nationalisation of the commissioning of GP services that has taken place.)

GPs will be key to integrated care. Indeed it is very difficult to understand how there can be an integrated care pathway without them.

So if the NCB is going to carry out its statutory duty to develop integrated care, and if it is going to play its role in developing that part of the mandate on integrated care, it will need to radically develop the GP contract. That contract, like every other part of the NHS needs to contain incentives to develop integrated, not just episodic, care. Read the rest of this entry »

Fragmentation was built into the delivery of the NHS from its inception. That is why it finds creating strong patient pathways so very hard.

Filed Under (Integration, Patient involvement, Self Management) by Paul on 29-10-2012

There are many conservatives resisting NHS reform who sincerely believe that recent reforms (and for that matter those of 2001-7) have fragmented what has always been an integrated NHS. For them the reason the NHS finds integration so very hard is because all these reforms have introduced fragmentation through relationships such as commissioning and competition. Read the rest of this entry »

Real integration needs tough, powerful integrators

Filed Under (Contracts, GP Commissioning, Integration) by Paul on 30-05-2012

Over the last few weeks I have been outlining the different mechanics of new elements of reform that will be necessary if commissioners are going to be able to transform health care for NHS patients. A few weeks ago I mentioned the importance of them buying effective packages of self care. Last week I outlined two different approaches to the way in which commissioners contract health care and today I want to outline some of the radical thinking that is taking place about how the provision of integrated care can be developed. Read the rest of this entry »