I spent Tuesday listening to a number of illustrious, knowledgeable and committed speakers on the topic of integration, at an event run by the Westminster Health Forum chaired by Baroness Pitkeathley and Liz Kendall, MP, Shadow Minister for Care and Older People.

It confirmed that IMPRESS is thinking the right way and has much to contribute. Mark Britnell talked about value, and commended his organisation’s book Value Walks. This argues that we should move from thinking that ‘cost walks on two legs’ ie that healthcare professionals are a burden, to “value walks on two legs.’ This probably requires a “short-term adjustment to working hours coupled with a clinical re-design.  That way, staff will feel less pressure, costs will be reduced and both without impacting on quality of care staff.” This fits with Michael Porter’s argument that given the other options of rationing care, taking a pay cut or reducing quality, the one affordable health care option that can unite staff and managers is a focus on value, defined as patient-defined outcomes divided by the cost of producing those outcomes.  He also talked about telehealth, which of course, in COPD care doesn’t show good cost-effectiveness (or not without sub-group analysis and a review of the impact of the trial on the control group's access to services). However it reminded me of that great NHS Confederation publication Remote Control that showed how much more potential there is to use the phone!

Martin Roland referred to John Ovretveit’s work Does Improving Quality Save Money? This inspired our More for Less document that in turn led to our guide to the Relative Value of COPD Interventions recently applauded by Sir Muir Gray: BMJ 17 September 2012 BMJ 2012;345:e6192.   Prof Roland convinced us that there is little evidence yet that many integrated care projects reduce cost or reduce admissions. The reasons will be partly about supply induced demand – new services attract new customers, changing thresholds for admission and partly the lack of scale.   I’d argue that we are seeing some good examples of integration between primary care and hospitals in respiratory care where the integrated care physician employed by the hospital offers support to primary care colleagues to improve their capability to assess and care for people with asthma and COPD. There are a  number of integrated care consultants in Wigan, Salford and London to name a few.  They care about the population’s health, not just the hospital population and about upskilling general practice.  (We have the example of the LES in Islington that incentivises this upskilling too).  We've also good examples of primary care specialists doing the same. Our good practice examples pages contain a number of whole system examples, notably North Mersey and Knowsley the winner of the North West Regional Award this year.

I’d also challenge the focus on avoiding admissions. We know from Sarah Purdy’s work that a 1% increase in smoking in a general practice population leads to a 1% increase in admissions for COPD or asthma, so shouldn’t the integration focus firstly on population health outcomes such as reducing smoking and regard smoking cessation as a treatment which is every clinician’s business? And of course, there's more to be debated about when hospital is the right place, and what should be done to optimise the care an admitted patient receives (the BTS care bundle piilots, building on the CLARHRC work on discharge bundles are being rolled out now).

The NW London Integrated Care Pilot was an exciting illustration of large scale change and some real learning and sharing of data and consultation styles between primary and hospital care. On that point, I’d highly recommend the RCGP guide to care planning that summarises the findings of the Year of Care project, the Co-creating Health schemes, and provides a number of examples of measures of “patient activation” which is crucial to achieving co- (as opposed to self-) management.  It gets to the level of detail that reveals what could happen in a consultation: asking questions such as "how important is it to you" and "how confident do you feel?"  If we accepted that 80% of NHS business is going to be long term condition management and that behavioural change is a core skill, perhaps we’d make more rapid progress?

There was lots of talk about trust, courage and willingness. That takes me back to the beginnings of IMPRESS when there wasn’t a common understanding of what GPs could do, (partly because hospital doctors don’t see most of the patients who are well managed in general practice) or the potential for hospital services to work differently. We’ve come a long way, and have a great understanding of the strengths and weaknesses of general practice and hospitals and models such as GPwSIs, and integrated care specialists.

The session also reminded me of our social care and housing jargon buster and how helpful it was to learn more about alternative languages and cultures and the difference between an eligibility categorization and a condition-specific one. Sarah Pickup ADASS highlighted the structural problems of earlier identification of people through risk stratification, which is a core element of integrated care services: these people may not currently be eligible for social care, and therefore it will take a leap of faith to offer them local authority-funded services.

It was good to hear that the Care and Support Bill makes it a duty on local authorities to prevent ill health and integration.   It will need courage to pool resources but there are some good mental health models.

Gillian Leng of NICE reminded us that the NICE quality standard on COPD did actually cross from health to social care.

Look out for a new website http://www.findmegoodcare.co.uk/

Finally, in the London Respiratory Team we’ve begun to think about a personal provider manifesto in London:

• I am a long term condition clinician
• I care about value
• I know how to assess and support populations and patients living and dying with chronic lung disease and how to drive improvement and how to work with my commissioners
• I personally deliver high value care
• I can lay my hands on:

1. oA pulse oximeter
2. oA contact for someone who can use a spirometer
3. oA COPD action plan
4. oA range of quit smoking products
5. oA spacer
6. oStories and testimonies about PR
7. oRegister for COPD, asthma, stop smoking and end of life
8. oICS safety card
9. oDischarge bundle
10. oLRT and IMPRESS products
11. oPhone numbers for: stop smoking counsellor, PR service, mental health specialist, social services and blue badge coordinator, palliative care, commissioning tools (CQUIN, LES)

What do you think?

The next blog will give an update on where IMPRESS is going next is to consider how services might be improved and integrated for people with multiple morbidities that cause breathlessness.  However, as a starter - there are two very stimulating publications on the case for investment in mental  health services.

How Mental Illness Loses Out in the NHS by the London School of Economics

Investing in emotional and psychological wellbeing for patients with long-term conditions

by the NHS Confederation mental health network.