A consortium, led by Frontier Economics, and including The King’s Fund, The Nuffield Trust and Ernst & Young, was appointed by Monitor to consider issues relating to the delivery of integrated care. Their report is here. Under the Health and Social Care Act Monitor has a duty to “enable” integrated healthcare and integrated health and social care. “Integrated care” is a concept that has been defined in many different ways. A recent review of the literature on integrated care by Armitage et al. (2009) revealed some 175 definitions and concepts.  There is now a clear consensus that successful integrated care is primarily about patient experience, although all dimensions of quality and cost-effectiveness are relevant. A definition of integrated care that combines the experiential dimension with that of cost and quality means there are potential benefits from integrated care for current and future service users, the public, providers and commissioners.  This means that a working definition of integrated care may be around the smoothness with which a patient or their representatives or carers can navigate the NHS and social care systems in order to meet their needs.

According to the International Longevity Centre – UK, the current (non-integrated) health and social care system has several failures. They include:

• Lack of ‘ownership’ for the patient and her problems, so that information gets lost as she navigates the system
• Lack of involvement by the user/patient in the management and strategy of care
• Poor communication with the user/patient as well as between health and social care providers
• Treating service users for one condition without recognising other needs or conditions, thereby undermining the overall effectiveness of treatment
• Decisions made in the social care setting affect the impact of health care treatment, and vice versa

At the heart of this new model of care is the need to better integrate services between providers around the individual needs of patients and service users. As The King’s Fund’s review of the evidence for integrated care concluded, significant benefits might potentially arise from the integration of services (Curry and Ham 2010), particularly when these are targeted at those client groups for whom care is currently poorly co-ordinated.  In the NHS, integrated care could be particularly important in meeting the needs of people with chronic diseases like diabetes and chronic obstructive pulmonary disease; frail older people who may have several chronic diseases and be in contact with a range of health and social care professionals; and people using specialist services – for example, those involved in respiratory, cardiac and cancer care – where networks linking hospitals that provide these services have contributed to improved outcomes.  In some cases integration may even entail bringing together responsibility for commissioning and provision. This form of integration is important because it allows clinicians to use budgets either to provide services more directly or to commission these services from others through ‘make or buy’ decisions. The critical ingredients of integrated care are considered to be: defining the right populations, aligning the right financial incentives to support a variety of diverse healthcare providers (but primarily to ensure the highest quality in patient overall experience), improved accountability for better performance in a more coherent outcome of coordinated care, judicious use of information technology and other knowledge management resources, effective leadership, a collaborative (and competitive where appropriate) culture, patient engagement, and better and more appropriate use of resources according to multi-disciplinary relevance.

In this hypothetical innovation described below, patients, members of CCGs, and healthcare providers have access to a smartphone app called “Integrated care”.

Who is the end user?

A problem with integrated care is that it is likely that the same organisational structures would still exist – albeit with key agents, such as health care provider organisations, healthcare professionals including doctors, clinical commissioning groups representatives, and so on, but a better way of looking at this innovation is where all participants are members of a continuous ‘network’ of innovation; this would help to diminish perception of there being a hierarchy in healthcare, which is a source of considerable inertia in the current English NHS. A version of the app could be available to clinical commissioning group members, or directly to the patient, and of course data are shared with healthcare providers.

The advantage about giving the app directly to the patient would be that the patient himself or herself makes a decision about the care, based on up-to-date information about cost and quality of care (it would be necessary to ensure that accurate data are submitted). The main procedural problem is deciding how much money each person has to play with in a personalised budget – would it be higher or indeed without limit for an individual with multidisciplinary needs or lives a long way from their place of treatment? Indeed, should the budgets be limitless, or should there be some form of rationing in keeping with the finite resources provided by the English economy? Notwithstanding these massive issues, this app would be more in keeping of what the general public understands by “money following the patient”.

Rationale for an app

This app could be based around diseases or conditions, such as dementia, systemic lupus erythematosus, and diabetes, which very often affect more than one bodily system, or more than discipline (for example nurses, doctors, dieticians, physiotherapists, SALT experts).  The Department of Health initiated a two-year national programme of pilots to investigate the impact of providing integrated care. The national programme consisted of 16 specific initiatives, including: structured care for dementia, end-of-life care, older people at risk of admissions, long term conditions, chronic obstructive pulmonary disease, care for diabetes, and substance misuse.

The Kings Fund/Nuffield Trust Report has emphasised the potential value of an innovation-approach to this problem. They felt a need to allow innovations in integrated care time to embed locally, requiring longer planning cycles. For this innovation change to succeed, providers should be allowed to take on financial risks and innovate as approaches to integrated care often work best when some of the responsibilities for commissioning services are given to those who deliver care. They also set out a more nuanced interpretation of patient choice. Patient choice should be intrinsic to the provision of integrated care, however, it could also be a barrier to integrated care.

It would be hard to see such an app being truly automated, in that it would be inconceivable to think of an individual making a decision about integrated care without help of an appropriate expert. However, having an app supported on the cloud has its advantages. Notwithstanding the usual privacy and security issues (which exist even with online shopping with supermarkets), resources could be scaled according to the needs of the population, and the transfer of information freely across all parts of the network would be virtually instantaneous.

Barriers to integration which the app would seek to overcome:

• Quality of IT and communication system: having separate information systems with different formats for clinical documents and without a common access to service users’ information makes integrated care more difficult (i.e. inter-operability); apps are commonplace on a variety of media including Apple iphones and Google Android phones, and for example different operating systems?
• Risk aversion: health professionals often work under heavy responsibilities and may be over-cautious e.g. when transferring their patients to another organisation, or collaborating with other providers; using an app might itself might be symbolic of embracing a different cultural approach to the more cumbersome (and slower) paper handling of integrative healthcare administration?
• Service users choosing alternative providers: service users have freedom of choice regarding their elected place of care. However, this freedom can create deviations from the planned pathway of care and may cut across attempts to provide integrated care. Regulation has a critical rôle here, if the definition of ‘any qualified provider’ allows as many regulated healthcare providers to enter into a competitive market.

There are still problems that the app would have difficulty in overcoming, namely:

• Governance: it may be unclear who has ultimate clinical and/or organisational responsibility should anything go wrong. That may make individuals reluctant to discharge patients from their care into that of another clinician.
• Clinical practice: differences in how to treat patients between different institutions can mean a lack of consensus and unwillingness to transfer patients from one part of the system to another.
• Cultural differences: driven by some of the issues above but even also by management style, extent of delegation of authority, clarity over objectives and other factors that might affect willingness to share information, resources and service users.

Nonetheless, there are possible advantages of the app:

• Having structured relationships between service providers and with patients – co-location, case management, multidisciplinary teams and assigning patients to a particular primary health care provider
• Using structured arrangements for coordinating service provision between providers – coordinated or joint consultation, shared assessments, and arrangements for priority access to another service
• Using systems to support care coordination – care plans, shared decision support, patient-held or shared records, shared information or communication systems, and a register of patients
• Improving communication between service providers – electronic transfer of data could be facilitated through instant messaging, or audio/video conferencing (like Skype)
•  Providing support for patients  – access to the most-up-to-date information about the condition, and healthcare providers.