In the Five Year Forward View (5YFV), the Government pledges to bridge the divide between GPs, community services and hospitals, and develop new, integrated, cost-efficient models of care that provide a more joined-up experience for patients.
To achieve this, services need to be better coordinated and tailored to meet the needs and preferences of individual patients, their carers and families in order to replace episodic care with a more holistic approach.
But how can we move away from an NHS service that is fragmented and often poorly coordinated to one that puts the needs and experiences of people at the heart of service organisation and delivery? Integration in action NHS vanguards – which have been tasked with developing new models of care – are already demonstrating the variety of ways in which integration can be achieved from joining up GP, hospital, community and mental health services to integrating IT systems within a particular specialism across a region.
For example, clinicians in one partnership vanguard aim to provide community outpatient and diagnostic services from a single large practice, in order to expand a range of local social, mental and hospital services, and provide a single point of access to community care.
Another group has created a multidisciplinary, multi-agency team to review mental health policy and strategy to identify why patients become ‘repeat attendees’. This approach is helping stakeholders to understand the relationship between mental and physical health and social standing.
In another smaller, but equally powerful project, a clinical network is being created, providing timely and expert radiology care for patients across the East Midlands. Known as the East Midlands Radiology Consortium (EMRAD), the group comprises a consortium of seven NHS Trusts within the East Midlands working together, hosted by Nottingham University Hospitals NHS Trust.
The sheer variety of projects being undertaken by vanguards helps to explain why integration means different things to different people, and that unless planned changes are clearly communicated to stakeholders, misconceptions about what is being proposed can be a huge barrier to change.
Consequently, making smaller changes and introducing them from the bottom up, rather than the top down, can be a more effective way of getting key stakeholders, including clinicians, on board and making change happen.
For example, a new best practice pathway for the use of non-oral treatments in Parkinson’s was recently devised by clinicians themselves to make the referral process for these therapies more explicit.
The new guideline pathway, for the first time, gives clinicians a road-map for the use of non-oral therapy (apomorphine, intestinal levodopa gel infusion (Duodopa) and deep brain stimulation). For the right patients, these treatments can be life-changing.
The tool helps clinicians understand referral criteria and the local process for referral. The framework can be tailored to suit any locality and has been developed with the guidance of a steering group of movement disorder specialists, neurologists, care of the elderly physicians, specialist nurses and commissioners all facilitated by NHiS Commissioning Excellence.
Managing patients across the entire care pathway
When services are redesigned through integration, it is important to manage patients across the whole pathway of that condition from diagnosis to end of life care, rather than focusing on individual elements of care or disease stage. To achieve this, we need to outline the support needed from both a patient and professional perspective across the continuum of the disease in health and social care, map needs in line with NICE guidelines, if available, and provide an end-to-end service pathway.
The Health Management Organisation (HMO) style of management could be a useful area for pharma to consider in the future with pre-symptom identification, early detection and proactive lifetime management by an HMO.
However, in addition to HMOs, the NHS also needs to consider tackling co-morbidity issues and the complex health needs of the nation’s ageing population, and potentially provide more specially trained staff for this task.
Engaging with patients
Harnessing the experience and knowledge of patients, carers and health and social care professionals is vital when changing patient pathways through integration. Indeed, there is strong evidence that effective communication and engagement with patients, carers, the public and other stakeholders helps to improve commissioning decisions, patient satisfaction and service use.
To obtain this feedback, we need to get patients to tell us their experiences of their current care – is it good or bad? If we then process-map their experiences, we can use a shared decision-making process to identify what the best outcomes for them would be and implement them. We can gather this kind of information via face-to-face discussions, online questionnaires, videos, focus groups and participation in events for patients.
Last year, for example, NHiS Commissioning Excellence was asked to review neurology services in Worcestershire and produce a report and recommendations. To help achieve this, we worked with the three Worcestershire CCGs, local GPs and other health and social care professionals to host a ‘Big Conversation’ event in 2015. This aimed to capture the views of service users, carers and clinicians on neurology services in the area (see box below). The main findings from the event included:
- Patients wanted access to advice seven days a week since, for example, problems like seizures can strike at any time
- The need for Accident & Emergency departments to have appropriate information for the patients and family members so they are better informed
- The fact that local paediatric care was very good but the transition to adult services needed to be improved
- Better social care support and prescribing/administering support was needed
- More education on how to self-manage and maintain a healthy lifestyle was required.
The review has now been completed and a report has been produced that captures all the main areas of good practice as well as areas that require improvement. The report is helping the commissioners agree the way forward with local CCGs and ultimately achieve their objective of offering improved, integrated processes for neurology patients.
What can pharma do?
Understanding how services function is key to integration and providing an improved pathway. Utilising and interpreting data can identify issues that need to be addressed and highlight opportunities to improve patient outcomes and create efficiencies.
For pharma companies, this might mean initially utilising the RightCare Commissioning for Value packs to identify where there is unwanted variation in NHS services. Pharma can support organisational change through mutually beneficial partnerships with the NHS. With the Parkinson’s pathway, AbbVie, Britannia and Medtronic provided financial support for the pathway’s development as well as support to specialist centres delivering this treatment to ensure they could develop their own pathways.
Lundbeck and the Wessex Academic Health Science Network (AHSN) are another example of where pharma has used its expertise in developing new patient pathways.
In October 2014, Lundbeck entered a Joint Working Agreement with the AHSN to reduce alcohol-related harm in Wessex. The aim was to engage with local commissioners to develop and evaluate effective treatment pathways for patients with increasing and higher risk drinking levels. The service redesign for primary and hospital care aims to not only improve patients’ health, but also to reduce unnecessary NHS spend.
Primary care practitioners were supported to identify and treat the underlying cause when patients with higher risk alcohol use present with common symptoms such as depression, anxiety and stomach complaints.
Through the working agreement, the Joint Working Group aims to:
- Reduce drinking for those drinking at Higher or Very High risk levels by up to two risk levels as recommended by the World Health Organization
- Increase recognition in primary care of alcohol use
- Improve health outcomes for patients
- Reduce GP attendances and prescribed medication
- Reduce A&E attendance and hospital admissions that are alcohol-related.
We can see the added value pharma can bring to the NHS through partnerships to deliver integrated, patient-centric services. Through engagements like these, service transformation can be encouraged and supported.
The NHS needs to review many of its care pathways to ensure patients, carers and families have a meaningful say in how services are delivered but current pressures often prevent this happening. Pharma has a real opportunity for engagement here and should grasp it as soon as possible.
Sue Thomas is CEO of the Commissioning Excellence directorate and Paul Midgley is director of NHS insight, both at NHiS – providers of local healthcare intelligence www.nhis.com
