01.04.15
Acute hospitals and integrated care: what business are we in?
Source: NHE March/ April 15
The King’s Fund’s Hugh Alderwick, senior policy assistant to Chris Ham, and senior fellow in health policy Chris Naylor, discuss provider-led approaches to integration.
Hospitals and integrated care are often seen as awkward partners. The argument follows that integrated care, with its emphasis on strengthening and joining up care outside of hospitals, stands in contrast to the interests of acute hospitals and the incentives that they are faced with. The conclusion is that integrated care and hospitals don’t easily mix.
The growing number of acute hospitals in England actively involved in developing more integrated models of care offers a welcome challenge to this way of thinking. Our recent report, ‘Acute hospitals and integrated care: from hospitals to health systems’, describes the experiences of five hospitals like these in different parts of the country that are changing the way that they work to deliver services in more integrated ways.
One example is Northumbria, where the hospital trust works in partnership with general practices and other providers to join up services for older people and those with complex health and social care needs. Results have included reductions in the rate of emergency hospital admissions and financial savings shared between the trust and their commissioner.
The trust has also supported general practices to develop into federations and works with local GPs to deliver some specialist services outside the hospital’s walls.
Another example can be found in Sheffield, where commissioners and providers have established shared governance arrangements to jointly manage their integrated care programmes across the city. This has helped the hospital and local partners align their work around common goals and collectively agree changes to services (quickly). For example, a significant shift of resources towards intermediate care and community-based services was agreed and implemented over a period of just two months (more on page 24).
As well as vertical integration with out of hospital services, horizontal networking arrangements between hospitals were also being used to support the sustainability and integration of acute services, like joint ventures, visiting services or service-level management franchises. These types of arrangements are already common in the NHS, but are likely to become more important as hospitals struggle to cope with financial pressures, issues with recruitment and increasingly taxing clinical standards – particularly for smaller hospitals that are under pressure to maintain access to services.
Examples like Northumbria and Sheffield highlight the progress that can be made to integrate services within the existing system, where the barriers to change are often more about relationships and behaviours than the technical details. At the same time, the policy barriers to integrated care undoubtedly make this progress more difficult: integrated working is not something that comes easily in an environment designed to treat organisations and professionals as islands rather than systems and teams.
The next step for these organisations and the rest of the NHS is to broaden what we mean when we think about integrated care. Most integrated care initiatives in the NHS are focused primarily on integration between health and social care services, and targeted at patients – typically older people and those with complex care needs. While this is the right place to start, these efforts rarely extend into a concern for the broader health of local populations and the impact of the wider determinants of health.
Taking a wider focus, integrated care needs to be seen as part of a broader shift away from the fragmentation of services and moving towards an approach focused on improving population health. This will require acute hospital leaders to ask themselves the fundamental question of what business they are in: are they running hospitals, working with others to deliver integrated health and social care services, or part of broader systems focusing on improving population health and wellbeing?
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