Reconfiguration and its associated drive towards providing care closer to home throws up a number of challenges.
Specifically, as patients with long-term conditions make increasingly complex moves between primary and secondary care, demand management may occasionally disrupt the close working between generalist and specialist practitioners necessary for effective care.
As the chronic disease burden rises, specialists and generalists will need to work together more closely to better meet the needs of patients with long-term conditions throughout the time of their illness.
Unsurprisingly, many of the royal colleges are now looking at ways to erode the artificial boundaries between NHS organisations in order to restore the close working relationships that used to exist. In 2008, the RCP, RCGP and RCPCH, together with representation from the NHS Alliance Specialist Network, published its own concept paper Teams without Walls.
This argues for an integrated model of care in which multi-professional teams are designed by local clinicians and patients and cut across traditional interfaces.
The anecdotal UK evidence in favour of integrated working practices between primary and secondary care of this kind is considerable. There is also much evidence from the USA. However, an efficient mechanism to facilitate this integration has up until now been elusive.
While by no means perfect, practice-based and world class commissioning may offer new levers to initiate clinical integration, provided this involves patients, generalists and specialists working together to design patient pathways. The working party responsible for Teams Without Walls collected numerous examples which illustrate that, with imagination, integrated services can be achieved.
The common features of these services were clinical leadership and involvement; high quality partnership with professional management; primary and secondary care partnerships; committed and flexible commissioners; clear patient focus; clear governance arrangements; and agreed measures and standards to ensure continuous improvement.
Consequently the college is now working with the RCGP, the Patient and Carer Network and the specialties we represent to develop tailored models in order to define a high quality service. Such services could then be used by commissioners, in cooperation with local doctors (generalists and specialists) and patients with long term conditions, to plan pathways of care that put into practice these principles.
Linked intimately to the future success of this approach is the ability of both the generalist and specialist to learn to work in different ways in the future. Current and future trainees should be trained in integrated care and, during training, they should be supported outside hospital in the same way as in hospital.
Thus, the doctors have to change and lead change, a theme of Lord Darzi’s Next Stage Review. If local commissioners respond to this challenge, then the future is bright.
Tags: Darzi review, Integrated care
