Posts Tagged ‘Integrated care’

“Care costs preclude the ‘do nothing’ option”

By Mike Broad - 4th September 2014 10:20 am

The high profile Barker Commission has called for the integration of health and social care.

Here’s some key reaction:

NHS Confederation chief executive, Rob Webster

“Back in May, the 2015 Challenge Declaration set out the main challenges facing our health and care system. This Commission, led by Dame Kate Barker, has outlined in absolute clarity how we might move to solve some of these challenges and is a hook for the debate on how much we invest, where we put that investment and how we join health and social care together.

“While we might not agree with all the recommendations it puts forwards, we welcome its contribution to that debate. We know the impact funding and demographic pressures have on health and social care, and this report highlights the funding gap that is likely to exist in both budgets in the future.

“There does, however, appear to be a political vacuum on many of these issues. The task for politicians now is to address the real financial challenges facing the health and care system and establish a vision for how they want services to be funded. The NHS as ever is committed to ensuring care is delivered. The 2015 Challenge process will continue to contribute to this debate and the NHS Confederation will be the voice of NHS leadership as we look to develop a positive future for the health and care system.”

Professor Chris Ham, chief executive of The King’s Fund

“We asked Kate and the commission to tackle some of the most difficult issues in public policy. They have delivered a robust and convincing report, which remakes the case for change powerfully and makes recommendations that could provide a better and more generous care system based on genuinely long-term thinking.

“The proposals as set out by the commission may not appeal to politicians fearful of commitments to greater public expenditure, but these issues cannot simply be ignored. The commission is clear – there is no “do nothing” option. As the costs of what we now classify as social care grow, these will increasingly fall to individuals and families, creating fear, uncertainty and inequity on a scale that the public would find completely unacceptable if applied to health care. The recommendations are therefore radical – tinkering around the edge of our systems of care is not enough to deal with the challenges we face.

“The issue is not whether health and social care are affordable in future – they have to be paid for one way or another. The issue is how far they are publicly or privately funded and at what level of quality and decency. This report lays down a challenge to politicians of all parties to acknowledge the unsustainability of current funding for health and social care and to set out, ahead of the election, some of the difficult choices that need to be made.”

Barker: radically reshape health and social care around need

By Mike Broad - 10:12 am

The way that health and social care are currently organised and funded creates confusion, perverse incentives and much distress for individuals and families.

An independent commission established by The King’s Fund has concluded that a new settlement is needed for health and social care to provide a simpler pathway through the current maze of entitlements.

The commission, chaired by Dame Kate Barker, proposes a new approach that redesigns care around individual needs regardless of diagnosis, with a graduated increase in support as needs rise, particularly towards the end of life.

The final report of the commission recommends:

- moving to a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services

- social care for those whose needs are currently defined as ‘critical’ should become free at the point of use

- as the economy improves, free social care should be extended to those whose needs are currently defined as ‘substantial’

- by 2025, some support should be provided to those whose needs are currently defined as ‘moderate’ but this should continue to be on a means-tested basis.

It also recommends integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed care and support allowance) within the single budget for health and social care.

Although mounting funding pressures are being faced in both the NHS and social care, the commission’s report challenges politicians to look beyond the deficit and engage the public in a debate about future care and how it will be funded.

The commission calls on the government to plan on the assumption that public spending on health and social care combined will rise to between 11 and 12 per cent of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries.

A partnership model, in which the costs of social care will be shared between individual and the state, would be phased in over time to provide fairer, more consistent entitlements to social care.

The move to make all care free for those with critical needs would end the confusing distinction between social care provided in residential care homes and NHS Continuing Healthcare, which is provided free of charge in nursing homes – a huge source of frustration under the current system.

After careful consideration, the commission rejected extending charges for NHS services, with the exception of prescription charges. Instead, to pay for these changes, the report argues that the bulk of the additional funding should come from the public purse, with wealthier people and older generations – the main beneficiaries of the changes – contributing more.

To fund the initial roll-out of the new settlement, the report recommends:

- radical changes to prescription payments, reducing charges to as low as £2.50 but significantly reducing the number of prescriptions exempt from charges

- limiting free TV licences and the winter fuel payment for older people to those on pension credit

- requiring people working past state pension age to pay National Insurance at a rate of 6 per cent.

- The report also recommends that new recipients of NHS Continuing Healthcare should pay the costs of their accommodation, as those receiving residential social care do now.

As the more generous elements of the new settlement are phased in, the report recommends further measures to raise revenue:

- a 1 per cent increase in National Insurance contributions paid by those over the age of 40

- a 1 per cent increase in National Insurance paid by those earning more than £42,000 a year.

The report also recommends that a review of wealth and property taxation should be undertaken to raise additional funds.

The commission recognised that the Care Act and Dilnot reforms represent an important step forward but considered that they will not be sufficient to address the funding and service challenges that lie ahead.

Kate Barker, chair of the commission, said: “Our challenge was to look at the big and difficult questions about the kind of care system, and indeed what kind of society we wish for ourselves and our families. The prize, if this kind of change can be achieved, is huge – a more integrated service, a simpler path through it, more equal treatment for equal need, a better experience for people who need care and their families.

“We have concluded, as others have before us, that our system is not fit to provide the kind of care we need and want. We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall into the cracks between means-tested social care and a free NHS. This includes people at the end of life and those with dementia or other conditions where too often there is a conflict about who pays at the expense of what people need.

“Our proposals would continue a system where costs are shared between the private individual and the state but with the taxpayer carrying a heavier load of that cost than at present. The cost of a more generous settlement, though large, can be afforded if phased in over time.”

Costs of proposals:

- current spending on social care for older people stands at £6 billion (2014); changes to provide free care for older people with critical and substantial need would require an additional £2.7 billion funding

- costs of free care for critical and substantial need would rise to around £14 billion by 2025 – around £5 billion more than projections based on current entitlement.

A full breakdown of the commission’s funding recommendations and the revenue each would raiseis as follows:

- A reduction of prescription payments from the current charge of £8.05 per item to perhaps £2.50, retaining a cap on the amount any individual could pay in a year but with exemptions limited to those on low incomes (£1 billion a year).

- Limiting free TV licences for the over 75s and the winter fuel payment for older people to those on pension credit (£1.4 billion).

- Ending the exemption from paying National Insurance for people working past state pension age by requiring them to pay a rate of 6 per cent, instead of the standard rate of 12 per cent (£475 million).

- Requiring new recipients of NHS Continuing Healthcare to pay the costs of their accommodation on a means-tested basis up to a cap of £12,000 a year (approximately £200 million).

- A 1 per cent increase in National Insurance contributions paid by those over the age of 40 (£2 billion).

- A 1 per cent increase in National Insurance paid by those earning more than £42,000 a year (£800 million).

The Commission on the Future of Health and Social Care in England was established by The King’s Fund in June 2013. The commissioners include:

Dame Kate Barker, business economist and former member of the Bank of England’s Monetary Policy Committee

Geoff Alltimes, chair of the Local Government Association multi-agency task group on health transition and previously Chief Executive of Hammersmith and Fulham Council and NHS Hammersmith and Fulham

Lord Bichard, cross-bench peer and Chair of the Social Care Institute for Excellence

Baroness Greengross, cross-bench peer and Chief Executive of the International Longevity Centre UK

Julian Le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics.

The commission’s terms of reference asked them to explore whether the post-war settlement, which established the NHS as a universal service, free at the point of use, and social care as a separately funded, means-tested service, remains fit for purpose and whether, and if so how, the settlement should be re-shaped by bringing the NHS and social care system closer together.

Read the full report.

Ring-fence single NHS and social care budget

By Mike Broad - 9:52 am

The government must create a single, ring-fenced budget for the NHS and social care, with a single commissioner for local services.

This is the key conclusion of an independent commission established by the King’s Fund, which is calling for a new settlement for health and social care.

The way that health and social care are currently organised and funded, it says, creates confusion, perverse incentives and much distress for individuals and families.

The commission, chaired by Dame Kate Barker, proposes a new approach that redesigns care around individual needs regardless of diagnosis or assessment, with a graduated increase in support as needs rise, particularly towards the end of life.

The final report of the commission recommends:

- integrating Attendance Allowance, the benefit paid to older people with care and support needs (which would be renamed care and support allowance) within the single budget for health and social care.

- social care for those whose needs are currently defined as ‘critical’ should become free at the point of use;

The commission calls on the government to plan on the assumption that public spending on health and social care combined will rise to between 11 and 12% of GDP by 2025. These levels will be broadly comparable to current expenditure on health alone in many other countries.

A partnership model, in which the costs of social care will be shared between individual and the state, would be phased in over time to provide fairer, more consistent entitlements to social care.

The move to make all care free for those with critical needs would end the confusing distinction between social care provided in residential care homes and NHS Continuing Healthcare, which is provided free of charge in nursing homes – a huge source of frustration under the current system.

As the more generous elements of the new settlement are phased in, the report recommends further measures to raise revenue including a 1% increase in National Insurance contributions paid by those over the age of 40, and those earning more than £42,000 a year.

Kate Barker, chair of the commission, said: “Our challenge was to look at the big and difficult questions about the kind of care system, and indeed what kind of society we wish for ourselves and our families. The prize, if this kind of change can be achieved, is huge – a more integrated service, a simpler path through it, more equal treatment for equal need, a better experience for people who need care and their families.”

The commission recognised that the Care Act and Dilnot reforms represent an important step forward but considered that they will not be sufficient to address the funding and service challenges that lie ahead.

She added: “We have concluded, as others have before us, that our system is not fit to provide the kind of care we need and want. We propose radical change, greater than any since 1948, that would bring immense benefit to people who fall into the cracks between means-tested social care and a free NHS.”

Read the full report.

Personal budgets expanded for NHS patients

By Mike Broad - 9th July 2014 7:51 pm

Personal budgets are to be expanded and cover both the health and social care needs of vulnerable people, the new chief executive of NHS England has announced.

Simon Stevens wants to see the frail elderly, people with disabilities and those with serious mental health problems given joint budgets from the NHS and council-run social care services to spend as they see fit.

The hope is that five million people will be offered them by 2018.

Patients will be given a nominal budget - at least £1,000 - which they can then decide to spend on whatever care and services they want, as part of a drive to give patients more power.

GP and emergency care is not included, and they can use these the same as anyone else.

Nearly 650,000 people currently have a social care personal budget. Under 2,500 patients have them in the NHS.

Speaking at the annual conference of the Local Government Association in Bournemouth, Stevens set out the plans for a new Integrated Personal Commissioning (IPC) programme.

Four groups of high-need individuals are to be included in the first wave from next April 2015, although councils, voluntary organisations, and NHS clinical commissioning groups may also propose others.

These include people with long term conditions, including frail elderly people at risk of care home admission; children with complex needs; people with learning disabilities; and, people with severe and enduring mental health problems.

This will blend funds contributed from local authorities and NHS commissioners (CCGs and NHS England). Individuals enrolled in the programme will be able to decide how much personal control to assume over how services are commissioned and arranged on their behalf.

NHS England will now work with partners in local government, CCGs, patient groups and the voluntary sector to develop an IPC Prospectus which will be published at the end of July. This will formally invite local expressions of interest in jointly developing and participating in the IPC programme from April 2015.

NHS England will provide technical support to develop projects, and fund independent evaluation. Wider scale rollout of successful projects is envisaged from 2016/17.

Experience with pilots have shown that this approach has the potential to join-up services and funding at the level of the individual, for people who often need multiple services.

Stevens said: “We need to stop treating people as a collection of health problems or treatments. We need to treat them as individuals whose needs and preferences should be seen in the round and whose choices shape services, not the other way round.

“That’s the big offer the NHS increasingly has to make to our fellow citizens, to local authorities, and to voluntary organisations.”

£2bn extra health and social care integration fund call

The Guardian - 18th June 2014 10:59 am

Councils and the NHS need an extra £2bn “transformation fund” to help integrate services, says the chairman of the Local Government Association.

Sir Merrick Cockell said the additional funding was needed on top of the Better Care Fund, the £3.8bn project to bring together health and social care services. He also called for the fund to become a five-year commitment, rather than the year it is officially scheduled to last.

Speaking at conference organised by the King’s Fund thinktank in London, Cockell said a transformation fund would “ease the short term disruption to residents and to patients”, and that it would have to be a “significant” amount of extra money towards the £2bn mark.

However, Cockell’s general attitude towards the Better Care Fund seemed to be one of confidence, calling it “our best answer to the questions asked of us in these testing times”.

The Better Care Fund relies on pooled funding from local authorities and the NHS, with the intention of reducing pressure on hospitals by providing more care and support in people’s homes.

Read more in The Guardian.

Integrated care model holds key to solvency

By Jonathan Fagge, CEO of NHS Norwich CCG - 16th May 2014 8:58 am

A week in the life of a CCG chief executive

If winter is the season of pressures, spring is the season of workshops. I’ve attended four this week covering collaborative commissioning, 5 year plans, integrated care for Norwich, and Strategic Workforce Planning.

Regular attenders of these might sometimes substitute ‘talk’ for ‘work’ when they describe them, and for an outsider we must look at times like the Committee of the People’s Front of Judea, but system workshops endure because we have not yet found a better way to bring everybody together to tackle the problems none of us can solve on our own.

The workshop season has been particularly febrile this year; in part because of the very complex and ambitious planning guidance that requires us to plan five years ahead and pool health money with social care; but also because as problems go, we are having to face up to some big ones. Amongst them stride two colossi:

Balancing the budget

This financial challenge is expressed in a variety of ways - the cash, the demographics, the growing burden of disease, even the 24-hour society - but it all relates to the last six years of budget growth below wage growth and inflation, combined with increasing levels of demand for healthcare.

Each year it gets harder for commissioners to balance the overall budget for their system, and providers have to find efficiency savings of 4-5%. They’ve all done the easy stuff, and now have to find ways of cutting into the wage bill without reducing the quality of care.

Our mental health and community providers  got less than a 1% uplift this year, but they have to treat more people, pay a small wage increase of 1-2%, and face higher costs on equipment and consumables. Our mental health provider produced a five year plan that added these 4% challenges all together and described a 20% cost pressure over 5 years. It has been unhelpfully translated by the newspapers into a ‘20% budget cut for mental health’.

These headlines are technically wrong - Norwich CCG for example has increased its spend on Mental Health in 2014/15, and ring fenced at least that level of spend in 15/16 - but there is a truth at their heart.

We cannot pay any of our providers enough to continue with their existing models of care, there is little slack in the system to fund change, and so it becomes increasingly difficult for them to balance the books, and for us to get signatures on contracts.

We have a plan for Norwich that we hope will meet this challenge, and are excited about working with the Kings Fund for the next three years. We will create a whole system model of integrated health and social care for the City - improving  outcomes, reducing costs, and keeping people well, independent, and at home for as long as possible.

I believe this is represents our best chance of emerging from this period of austerity with the quality of care protected and our health system intact and solvent, but it will not be easy and we will need to work together to make it happen. And if an occasional workshop brings us together, reminds us of the mission, and creates a space for us to iron out the tensions, then I will happily sit cabaret style with a mug of coffee and some flip chart paper and give it my undivided attention.

The retirement challenge

The workforce challenge has had less coverage than the money, and yet in some ways it is of greater concern.

In Norfolk and Suffolk, 17% of the health workforce are over the age of 55, and are expected to retire within the next five years. I am told by the Local Medical Committee that almost half of all surgeries in Norfolk have at least one GP vacancy. We expect to be 2,000 nurses short of requirements in Norfolk and Suffolk by 2019. We already need 400 more paramedics for the East of England. And many hospital departments - especially A&E, Stroke, Medicine for the Elderly - report increasing difficulty in recruiting consultants.

Unlike the money problem, government cannot simply turn the tap back on. It takes between two and ten years to train people into these various careers; double the number of nursing commissions at Universities tomorrow and they will begin to join the wards, surgeries, and patients’ homes in the summer of 2018.

Do the same for doctors and it will be later than 2020. The paradox is that although we are training fewer than we need, we are training as many as we can afford.

Health Education England is responding to this challenge -  looking for efficiency savings that will enable them to increase the number of commissions they can afford. Even more importantly they are investing in the training, support, qualifications, and greater recognition for the health support workforce, known internally as ‘Bands 1-4′.

If we can standardise the training and produce a nationally recognised qualification we could quickly create a large skilled and transferable workforce able to perform a variety of health support tasks, and freeing up the time of doctors and nurses.

I have taught on HCA courses in the past (from new to ready to go can take as little as three months), watched them provide care, and talked to both doctors and nurses about the opportunities for sharing their workload with trained assistants. I believe there is huge scope for reducing the costs of care without reducing quality, and this initiative should be a major part of the puzzle to the workforce challenge we face.

I asked a senior clinician that worked on our Urgent Care Unit trial this winter about what had made it so successful. He talked about the developing relationship between community and hospital staff, the proximity of the unit to A&E, and the speed of treatment and discharge.

But top of the list was the Healthcare Assistant that drove frail patients home, settled them in, and made sure they were comfortable and safe. Each journey almost certainly prevented a patient being admitted. This wasn’t nursing on the cheap; it was professional and appropriate assistance that made nursing care on a ward unnecessary.

So, money is tight and workforce is ageing? All hail Bands 1-4!

11 health areas to receive help with planning

By Mike Broad - 17th February 2014 1:21 pm

Eleven financially-challenged health economies in England are to receive expert help with strategic planning in order to secure sustainable quality services for their local patients.

Monitor, NHS England and the NHS Trust Development Authority have agreed to fund a series of projects to help groups of commissioners and providers work together to develop integrated five-year plans that effectively address the particular local challenges they face.

As part of the annual planning round, all NHS organisations are being urged to plan over a five-year period in future as part of a concerted effort to tackle the long-term financial and operational challenges facing the system.

The eleven areas have been chosen on the basis that they will most benefit from external support in the first few weeks of the new financial year, and potential suppliers are now being invited to tender for the work.

Responsibility for delivering strategic plans remains with the individual commissioners and providers. The appointed supplier will act as a critical friend, seeking to bring together all partners in the health economy  and testing whether the organisations are undertaking their long term strategic planning in the most effective way.

Suppliers will be appointed at the end of March and will begin a programme of work lasting around 10 weeks across four work streams;

- A diagnosis of supply and demand;

- Solutions development and options analysis,

- Plan development;

- Implementation.

NHS England’s Chief Financial Officer Paul Baumann said: “We are investing resources now to help organisations across these health economies to plan effectively. The health economies identified are those where we believe that this immediate support will have the greatest long-term impact, providing significant positive benefits to patients and taxpayers in the future.”

The 11 health economies are:

1.            South West London

2.            North East London

3.            Cumbria

4.            Eastern Cheshire

5.            Staffordshire

6.            Mid Essex

7.            Cambridge & Peterborough

8.            Leicestershire

9.            Northamptonshire

10.          East Sussex

11.          Devon

Taking out the barriers to integrated care

By Dr Leonid Shapiro and Dr Michelle Tempest - 5th December 2013 10:54 am

Commissioners, whether at NHS England, Clinical Commissioning Group (CCG), or local authority level, are increasingly looking to integrate care across hospital and community as well as health and social care.

It’s the only way for the system to gain enough efficiencies to be able to deal with the massive growth in demand from an aging population increasingly living with long term co-morbidities. This has resulted in the fundamental shift from giving contracts to the local incumbent NHS provider of a specific (‘silo-ed’) service to any lead provider (NHS or private) providing care to an entire population.

This has a number of implications. First, is the idea that private organisations can compete on a level playing field to NHS incumbents. Section 75 rulings, which require CCGs to tender out all services to all providers rather than automatically giving them to the local NHS provider, is a fundamental driver of this. Even heavily pro-NHS CCGs are now being forced to consider if private providers can offer a better deal for the population they are responsible to look after.

Second, payments for care are shifting from activity based, per-procedure for example, to capitated population base (fixed amount of money for looking after all care needs of over 65 year olds, for example). This puts the onus onto the provider and changes the incentives, not to just deliver an increased number of procedures, but to better maintain the health of the population so that they don’t need to do so many procedures, completely changing the way providers view the world and their purpose.

Third, it is impractical for one provider to deliver all care under an integrated care contract and increasingly providers are either partnering (including partnerships between NHS and private providers) or subcontracting some services. The concept of prime contractor has surfaced whereby a main provider contracts with the CCG and then subcontracts other providers (some of whom may have unsuccessfully bid one the same contract tender) to deliver the care.

Alliance contracting, common in the construction industry for complex projects, has become popular now in healthcare. Under alliance contracting, the prime contractor creates a special contract with the subcontractors where payment is not based on individual subcontractor performance, but on the performance the service overall - linking every member’s success in the contract to one another. This creates incentives for subcontractors to help out each other and ‘pull in the same direction’ as they are ‘in the same boat’. It also reduces the complexity of contracts between the providers and litigation.

As a result of this doctors and multidisciplinary teams will have to work with care coordinators, perhaps employed by lead providers, perhaps from the private sector, to look after patients. This shift from a purely clinical, doctor-led approach to care to a more managed full patient pathway approach should start linking up clinical pathways, rather than encouraging the status quo of ‘silo-ed’ service delivery, and integrating care using fact backed evidence.

Data will also become more important. Currently, patient clinical data is only available to the organisation that delivers the care direct to the patient. For example, the CCG does not have visibility over how money has been spent by acute providers and even less visibility over how block community and mental health provision has been allocated.

They also do not have access to clinical data held by providers, making it impossible to review outcomes, identify patients getting dis-coordinated care, and create an integrated care strategy on a whole system basis. This has to change. If commissioners, lead providers, and subcontractors are to deliver integrated care, to improve patient care, patient experience, and reduce cost inefficiencies, they must be able to analyse and leverage big data sets from all stakeholders.

Current legislation prevents this from happening and much work is needed to clear the road to data sharing in this brave new world.

Dr Leonid Shapiro is managing partner and Dr Michelle Tempest, a partner, at Candesic, a strategic consultancy serving the NHS, private operators, and investors.

14 pilots announced as integrated care leaders

Social Care Worker - 4th November 2013 7:19 pm

Fourteen areas are leading the way on integrating health and care, the care minister says, and he wants their learning to spread across the country.

The pioneers have been selected by a renowned panel of experts, including international experts drawing together global expertise and experience of how good joined up care works in practice.

The aim is to make health and social care services work together to provide better support at home and earlier treatment in the community to prevent people needing emergency care in hospital or care homes.

Read more at SocialCareWorker.

NHS can learn from NZ’s integrated care story

By Francesca Robinson - 1st November 2013 11:07 am

A joined-up approach to healthcare which has transformed care in New Zealand could have important lessons for the UK government as it seeks to integrate health and social care.

Since 2007 Canterbury District Health Board (DHB) has embarked on a major investment in community services which enable more people to be cared for in their own homes.

This has relieved pressure on hospital services, reduced inappropriate admissions, ensured timely discharge of patients and reduced readmissions.

The Board has moved from a position where its main hospital in Christchurch, struggling with unsustainable demand, regularly entered gridlock with patients backing up in its emergency department and facing long waits as the hospital ran out of beds – to one where that rarely happens.

In the last three years, despite the upheaval of the earthquake in 2011, patients have been saved 1.5 million days of waiting for treatment and almost 25,000 patients cared for in community settings have avoided a hospital stay altogether.

The goal has been to build capability in general practice giving GPs good access to services such home nursing care and meals on wheels and secondary care support and advice, making them a single point of continuity.

GPs have also been provided with direct access to a range of diagnostic tests. This has enabled increasing numbers of patients to arrive for outpatient appointments already “worked up” with their need to see a specialist already established.

A range of conditions that once were treated purely or mainly in hospital are now provided in general practice – for example, the removal of skin lesions in a country with a high incidence of skin cancer, and treatment for heavy menstrual bleeding.

A shared patient record, a well-resourced out of hours service and a triage tool which enables ambulance officers to ring the general practice team, all help to keep people needing emergency care out of hospital.

Carolyn Gullery, DHB general manager for planning and funding, says their mantra is “one system one budget” and the ethos is that everybody works for the one service – the Canterbury health system.

“Also we are really good at using information to drive service change. Our vision is one of a connected health system, centred around people where data is the major driver of change.

“We work with a UK organisation called Lightfoot and we use them to make information available and live to the system. Because it is live we can interrogate the data and see what’s really going on. Also it enables us to figure out what next bit going to improve.”

She says lessons the UK could learn are:

- If you are going to integrate services develop a shared vision: everyone needs to be seeing the ultimate outcome as the right outcome.

- Remove financial incentives from contracts. Design the way the system needs to work then figure out how to fund it.

- Join up the data: that way you can see solutions that may otherwise be hidden.

- When aspiring towards an ED target of under 4 hours look carefully at what is happening in primary care.

- Make sure out of hours services are well resourced and make sure only the right people are brought into hospital from primary care.

- The whole system, primary, secondary and social care, all need to work together.

“The key behavioural change for us was based on developing trust between primary and secondary care and with the whole system. It is important that everybody comes to work each day expecting to do a good job and are going to make the system work.

“We have created a virtuous cycle. People get faster access, care is provided at home and people stay out of hospitals. Integration is more of a journey than a destination. We have proved to ourselves that it is a journey worth taking,” she says.

In a report on New Zealand’s quest for integrated health and social care the King’s Fund said recently that “Canterbury’s story deserves careful study and adaptation if the commitment to integrated care is to be translated into practice.”

“Canterbury DHB could provide some of the solutions the NHS so badly needs,” it concluded.