Debate & AnalysisFollow the yellow brick road:integrated care - can we do better?

PATHS OR PATHWAYS OF CARE?'Follow the yellow brick road'. That's whatpatients are supposed to do, Embark on apathway, follow it and reach theirdestination, medical care achieved. Well,doctors have difficulty with this concept.Pathways often become rigid andprescriptive, sometimes the actual pathtaken is a winding convoluted yellow brickroad, with multiple stops and deviations.Patients deserve better. A quick smoothroute, where each step in the actualpathway is linked together, where thedestination of health and recovery isreached directly and efficiently. Enthusiastspoint out that improving patient care byproviding a pathway based on nationalguidelines, has clear advantages. Otherswould state that pathways are simply acrude guide for the inexperienced, a basicmap for the unfamiliar? Fixed pathwaysshould deliver gold standard health care,through best practice. Local areas adaptingto achieve the ultimate safe, efficient, andcost-effective goal of patient care. This isintegrated health care. But is this actuallyhappening?

PATIENTS LOST WITHOUT HELP?Gapsexist within healthcare systems, whichprevent patient pathways from beingsmooth and direct. Patients can disappearoff the pathway for days, deviating from thepath, lost in the system. Examples are daily.Mrs Smith, admitted by default with atreatable at home chest infection, on aFriday night, has a delayed dischargebecause of the absence of social care andphysiotherapy access, then picks up aurinary tract infection, leading to a DVTonthe ward, followed by problems withcoordinating INR management at home.

While the pathway may be good inprinciple the practical organisation andimplementation is not always smooth.Issues occur in both primary care,secondary care, social care, private care,and voluntary care. Each sector can see theproblems. However sectors are not, as yet,consistently working effectively together inan integrated way to share these problemsand to attempt to prevent futurerecurrences.

How many consultations across the NHSare wasted, handling the frustrations,anger, and morbidity arising from thebarriers and gaps in the paths of patient

care? Complaints are but the tip of thisiceberg. Absorbed and then ignored, there isoften no process to funnel thesefrustrations and to convert them into afeedback process to improve the pathwaylocally. Complaints are actually thegoldmine of advice, which used on a biggercollated scale as feedback could and shouldimprove local pathways, tailor them to ·localneeds, and result in financial savings.

MISSING AN OPPORTUNITY FORINTEGRATED HEALTH CARE?There remains a genuine wish and impetusto move forward. All those involved in healthcare, without exception, want to seeprocesses work better. More seamless,more integrated care. Clinicalcommissioning still remains an opportunityto improve practice across primary andsecondary care. The risk is that theevolutionary process becomes derailed.Instead, focusing on reorganisation ofregional administration and managementrather than improvements of local clinicalcare and the education of clinicians inservice provision and pathways, Mostexamples of good practice, involve bringingeveryone in the whole care pathwaytogether in a multiprofessional approach,The hiccups in a patient's care pathway areoften organisational, a delay to get an X-ray,a CTscan, access to physiotherapy, obtain awalking stick. The key is having a practicalway to bring the lead clinicians together fora short focused period to highlightproblems in the care pathway and to solvethem together so that another problemelsewhere in the system does not result.

DRIVERS FOR CHANGEIn many cases the drivers for change areactually the marked reduction in budgets.Organisations are forced to actively look atpractical ways to make savings, At times ofausterity there are clear benefits in

collaboration and pooling of resources, Thehealth and wellbeing boards are an obviousvehicle for this if used effectively. Theconcern IS that these are beingunderutilised. The incentives forimprovement of care are actually more nowthan when the NHSwas in receipt of greaterinvestment. More efficient, community-based services can be achieved throughdiscussion of complex cases, riskstratification, shared case planning, andcomparison of outcomes acrossmultidisciplinary groups using a reportingof metrics.

WHO'S IN THE DRIVING SEAT?GPs are said to be leading this, but theymust retain a dispassionate overview of theprocesses. GPs must avoid a GP-centredapproach by looking at the whole serviceacross all sectors of care. Primary care iswell placed to provide feedback on systemsand to facilitate improvements. Success canbe achievedvia collaborative working acrossbundles of clinical pathways, while stillretaining a focus on patient care. Butclinicians need to actively seek the widerview. Applying Mintzberq's principles ofreflection, analysis, collaboration, action,and worldliness could help to preventclinicians becoming entrenched in thenarrower perspective of their individualclinical silo.

WHAT IS NEEDED?Well, easily accessible, local factmanagement databases are essential, butthey are as yet, embryonic in their evolution.'Map of Medicine' is a national project,which lays out clinical care pathways andhas brought clinicians together in teams todiscuss pathway patterns as clinicalreference groups. Map of Medicine is a goodbegin, starting to establish local informationand local guidance. Adding in a moreeffective 'wiki' element may empower local

"How many consultations across the NHS arewasted, handling the frustrations, anger andmorbidity arising from the barriers and gaps in thepaths of patient care?"

British journal of General Practice, August 20121441

"Complaints are but the tip of this iceberg. Absorbedand then ignored, there is often no process to funnelthese frustrations and to convert them into afeedback process to improve the pathway locally"

healthcare workers further by allowingthem to edit and add local relevantinformation directly. Whatever systemdevelops,what is clear is that rapid retrievalof user specific information during eachconsultation is essential. Clinicians cannotpossibly remember everything. A factmanagement system, that rapidly indexessummary points, linking to more detaileddocuments would be a major innovation.'Local Linked Addresses Management andAdvice' is such an example, reviewed by theUniversity of Winchester and the WessexDeanery. It is tailored and focused, with localuser input, but is not as yet in a format thatcan be applied nationally.

KEYS TO SUCCESS'Integrated care' is now part of the nationaloutcome framework for the first time and afocus of one of the four main work streamsof the second phase of the Future ForumPhase. Sharing and analysing models ofsuccess rather than reinventing the wheelcan only be good for national development.Successes invariably involve a lead clinicianand a lead administrator. When the patientis stuck or lost in the system, the leadclinician and administrator are available totackle the issue. They are a focal point ofcoordination and feedback, essential to thefuture success of clinical care pathways.

FEEDBACKThere is a need to find an easy route offeedback to improve care pathways.Nationally there is currently no clearmechanism in place for local patient andclinician feedback. What we have is eitherlabelled as 'patient complaints' or is'feedback on whole organisations' such asthat undertaken by Dr Foster. A websiteportal which can collate information relatedto a particular bundle of care pathways mayprovide the answer. This could be linked tosites such as Map of Medicine. There is arisk that the sheer volume of commentcould simply overwhelm, but it is the patternof feedback more than the detail, that willguide lead clinicians on where to focus.Examples of good practice are beginning to

emerge. One is a clinical dashboardupdated on outcome measures of patientcare which has been applied in severalspecialities at Salisbury NHS FoundationTrust. Other examples of integrated care aredescribed where there has been improvedhealth care with significant cost savings.Examples include care for older people inTorbay, COPD care services in Somerset,and diabetes care in London which havebeen described at the King's Fundconferences and in the King's Fund reports.

ADDRESS FOR CORRESPONDENCEMark A RickenbachThe Wessex Deanery and Winchester University,Southern House, Sparnow Gnove,Otterbourne,S021 2RU, UK.

E-mail: ricklilchandlers.prestel.co.uk

EDUCATIONEducation underpins the whole process.Education about the key contacts, educationabout how to access the information,education about who is available to providecare, education about how to refer.Education for all members of the carepathway and in particular for those involvedin commissioning of care should be at theforefront of all planning. Information needsto be provided in easily recalled concepts,nuggets, and bytes of information. Whatwere first called skills networks and arenow known as local education and trainingboards [LETBs] could be pivotal in this andhave the potential to provide amulti professional approach with a focus oneducation related to pathways of care ineach specialty. LETBs could bring togethertrusts, deaneries, colleges, and medicalcommittees, plus medical, non-medical,public, and private stakeholders. Concernsexist however that primary carerepresentation on LETBs is vastlyovershadowed by secondary carerepresentation. Sitting alongside health andwellbeing boards, with the rightencouragement, LETBs have the potentialto improve the care of the whole population.

Improvement Science Fellows and ServiceImprovement Fellows are all being trialledin Deaneries such as Wessex.What makesa difference is meeting together andworking face-to-face in localities. It is thisbottom up rather than top down approach,using the principles of action learning andaction research, that produce lastingchange. The review, feedback, change, andreview approach needs to be embedded inclinical commissioning contracts at locallevels. Clarity on routes of feedback and arequirement for named clinical andadministrative leads js essential forsuccess. Listen to those along the yellowbrick road and in so doing undertake tocontinually improve the route.

IS IT ACHIEVABLE?Goodexamples do exist. The King's fund 'GPWhole Systems Leadership' approach helpsdoctors to focus on a specific path of careand facilitate improvement. The LondonDeanery has set up education for integratedcare in specific specialties. The RCGPhas anetwork of Clinical Commissioning leads.

Mark A RickenbachGP,Associate Dean and Honorary Professor, TheWessex Deanery and Winchester University,Healthcare Education and Quality, Otterbourne.

Clare WedderburnGP and Associate Dean, Wessex Deanery, GPCentre, Bournemouth University, Bournemouth.

ProvenanceFreely submitted; not externally peer reviewed.

©British Journal of General PracticeThis is an abridged version of a full-length articlepublished online. Cite this version as:Br J Gen Pract 2012; 001: 10.3399/bjgp12X653750(abridged text, in print: Br J GenPract 2012; 62:441-442).

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