The people who are best placed to ‘integrate’ health and care are the people who use the service, argues Merron Simpson
Whether your definition of integration is vertical (integrating primary and secondary care) or horizontal (integrating health, care and housing), well-established systems with their own built-in incentives and rewards make it difficult for professionals embedded within them to fully integrate the services they are ‘responsible’ for. I’m optimistic that progress can be made to streamline our systems so that they work more fluidly together, and I think we will move faster and stand a greater chance of success if each profession makes patients/customers/residents the focus of their activity.
People using health, care and wellbeing services don’t necessarily see the boundaries that professionals see and when they do, it is usually because of their past experiences of receiving care within a disjointed system. Evidence suggests that the NHS falls down at the point at which individuals need to move between the silos. Instead of shifting between the silos through ‘referrals’, enabling people to put together their own individualised ‘package’ and draw the right combination of services (from hospitals, their GP surgery, care providers and a variety of community providers) to themselves makes a lot of sense. People themselves can do a lot to manage their health and they usually know what will make their lives work better.
Recently, I have been putting about the idea of replacing Care Pathways with ‘People Pathways’ particularly for people managing long-term conditions: I mentioned this idea in a Tweetchat to crowd-source the NHS Alliance’s submission to the RCPG Inquiry into Patient Centred Care, with housing colleagues at the National Housing Federation Care and Support Conference, and in a debate with NHS Alliance colleagues and the Foundation Trust Network. So far, I have had positive noises from all angles suggesting a wide recognition of the limits of traditional Care Pathways that address people’s medical conditions, but overlook the person as a whole.
What if each individual living with one or more LTC was supported to develop their own personal ‘People Pathway’ containing the necessary medical elements and other things that are important to them as individuals. It could also include things the individual agrees to do themselves to promote good health and make their lives better. Providing patients with access to their health records is an important first step to create this jointly produced plan, but hospital consultants and GPs would only need to be responsible for certain (mainly medical) elements; a third party (community partner) would work with the person to help them to define other elements and access a range of relevant services available in the community. People pathways might include, for example:
– Medical elements: eg, tablets to be taken, treatment, medical procedures in surgery or hospital
– Nursing elements: eg, help changing dressings, home dialysis
– Care elements: eg, home visits, personal care
– Social elements: eg, befriending schemes, special interest groups eg. knitting, fishing
– Housing elements: eg, fixing boiler, putting in downstairs toilet, moving to more suitable home
– Practical elements: eg, dog-walking, help filling in forms, cleaning, gardening
– Exercise elements: eg, Tai Chi, gym
– Advice elements: eg, financial and benefits advice, will-making, housing options
– Self-management: “I will test my blood sugar level twice a day and report to my GP if it is under/over a certain level”, “I will avoid foods that are high in cholesterol”
People Pathways containing only things that really matter to the individual and moulded around them would span health, care, support, housing, community and the patient themselves in a single plan. While the individual would be in the driving seat, they might ‘access’ several different types of statutory, voluntary, and community-based organisations such as Age UK, Citizen’s Advice, Home Improvement Agencies, social enterprises and local businesses. This wouldn’t change the way services are paid for or who pays, except that it would bring funding streams together into a single plan that makes sense to the individual. Something similar, the Self-Directed Support Plan, already exists for people in receipt of personal care budgets. People Pathways would be much broader – they would contain medical (current Care Pathway) as well as other elements and they would be for anyone with a long term condition, irrespective of their eligibility for funding.
I suspect that Simon Stevens’s recent announcement about personal health and social care budgets may be partly to persuade medical professionals that their patients (and not themselves) are the real experts on how they can live their lives well. Also, that the medical model of health, the domain of the NHS and doctors in particular, is not the only vehicle through which people get well and stay well. Other things, apart from medication, treatments and personal care, matter to people and can make all the difference for someone living with a long-term condition between living a miserable or a full life.
But PHBs are contentious and the downsides have been well documented. Could ‘People Pathways‘ which focus first on how people want to live their lives and second on who will pay for the various elements be a more constructive vehicle for integrating across silos and improving people’s experience of ‘the system’ as a whole?