Integrated Care: Its clinicians that make the difference

As clinicians we want to work in the health service to provide better care for our patients.  The only way we can do this is by being part of a team. The same is true for our social care colleagues. The relationships we have with other clinicians, managers and health and social care partners are absolutely vital if a community is going to meet the difficult financial challenges ahead and yet deliver the highest possible quality of care.

In Northamptonshire we formed our Integrated Care Partnership (NICP) in 2009.  We invited senior clinicians and front line workers from all major providers (including the LMC as the provider arm of primary care), as well as patients, carers, social care and the voluntary sector to come together with the aim of providing better integrated care to our mutual patients.  Our ambition was to use this partnership to break down and resolve all organisational barriers and interface issues.  We identified a series of quick wins that quickly established the value of the partnership, which still commands the attendance of all organisations 31 monthly meetings later!

We agreed a set of shared markers of success: decrease in emergency admissions and readmissions, decrease in length of stay, decrease in admissions to care homes, and ensure that we are able to honour the wishes of more patients in terms of their preferred place of death. Who could argue or put organisational barriers in the way of these markers?   We agreed that we would use the partnership to ensure that the right clinical leaders come together in the right meetings at the right time to make all of the important decisions.

We have already seen a 17% (440 patients) reduction in deaths in hospitals compared to last year following the introduction of new end of life service.  However, the most successful and ambitious scheme has been our £3 million Community Elderly Care Service. This all started when a Consultant Geriatrician asked me for 20 minutes on one of our agendas to present the concept. We quickly harnessed the collective enthusiasm around the table and ensured that doors of organisations on which we previously had to pound on heavily to find a solution were flung open due to the collaborative bottom up approach. The business case was quickly developed, piloted and approved. 

We are never going to agree on everything.  What we have developed over time are strong personal, as well as organisational, relationships that enable us to tackle differences of opinion in an open and constructive manner. For example, we continue to reconcile our ideological differences of the most appropriate place of care for patients by working our way through our Consultant to Consultant referral policy to agree exactly which patients should be seen where.  Because we have the right senior clinical leaders in place we can openly discuss and resolve all issues within the NICP.  We do not need to escalate to any higher authority, and in fact we would see this as a failure of our partnership.

Once we agree a collective course of action, each clinical leader takes this back to their organisations and ensures the appropriate changes are made. Where change is not delivered and there are further obstacles to be overcome we bring this back to the partnership and work together to resolve them.  The hearts and minds battle is so much more easily won when clinicians are leading and driving the change.  

The difference between a PCT and a Clinical Commissioning Group – a GP Chair Perspective

Guest Blog by Darin Seiger

Darin Seiger is Clinical Chair and Accountable Officer of Nene Commissioning.  He has been GP Chair of Nene Commissioning since it was established in 2007.

I still remember the shock and disappointment I felt during the lecture in my 2^nd year of medical school when we had the session on “How the health service is actually run” – how the hell had the model evolved where managers make all of the important decisions including whether to even involve clinicians at the coal face? Madness!

Well here we are as clinicians, after years of saying we want more power and influence, ready to seize this opportunity and take these responsibilities on.  But individual clinical leaders who have grasped this vision need the support of all their local clinicians.  We have to rise to this challenge and win the hearts and minds of our generalist and specialist colleagues to work with us as a team. To do this we have to show that we mean business and that we will make a difference and not end up repeating the previous cycle of promising change and delivering the best part of bugger all.

Two years ago I called up the Medical Directors of our main provider units (two Acute, one Mental Health, one Community provider and the LMC Chair - as the provider arm of primary care) and suggested the six of us, with our combined 128 years of working in Northamptonshire, needed to start working together to provide the leadership to drive collaboration across our organisations.  We have built the crucial relationships between us, and now, through our Northamptonshire Integrated Care Partnership (NICP), we are working together to drive clinically led change though our health and social care system. 

As clinicians we can now stop asking for permission to make changes to improve the care for our patients and just get on and do it.  Implementation of our clinical ideas (‘product’) is king, and without our managerial colleagues to turn our vision into reality, we would not have the capabilities to deliver ‘product’.  We are very lucky in Nene – we have a dedicated management team that passionately believes that clinicians should make the important decisions and effectively we are committed equal partners in our determination to make change happen.

The exciting part is that as clinicians, we can break through barriers that no managerially-led system could ever do, in terms of shaping and delivering better clinical care.  We don’t need the nth degree of evidence and bureaucracy to make a decision to commission a new pathway or service because as clinicians we know they changes will deliver higher quality of care and return on our investment.  Where historically it has taken months for business cases for new services to be agreed, as clinicians we will not tolerate these delays in the system.  Ultimately we know that delays in services starting are delays suffered by our patients.

Put simply the differences between a PCT and CCG are:

·         Collaborative bottom up approaches to solving issues and designing better care for our patients whose pain and frustration we feel when things do not go right

·         Understanding that clinicians need to understand and be consulted on what the issues and potential solutions could be – it simply raises clinicians’ antibodies to be told “this is the problem and this is the solution”

·         Local leaders, with long and deeply embedded roots in our practices and communities, see ultimate success as what is achieved locally, and do not view these leadership  positions as transitional until the next opportunity comes along