A new type of organisation for a new time
The need for integrated care organisations
In 1948, it made sense to have an acute healthcare system. In 2015, it does not. Instead, we need integrated care organisations (ICOs). These remove the boundaries between:
- Health and social care. The creation of separate funding and delivery structures for health and social care was an accident resulting from a post-war political power struggle in the Labour government16.
- Acute and chronic medicine. The patient journey through community care and within hospital is disorientating and confusing17. The concept of chronic disease management is well developed in countries such as the United States, but poorly developed here.
- Generalist and specialist skills. There is a growing separation of clinical expertise between those who can consider the “whole person” and specialists in increasingly narrowly defined disease groups.
- Primary and secondary settings. GPs play a vital role in the care system. However, traditional surgeries are not home to the range of technologies and skills that will allow GPs to reverse, for instance, the United Kingdom’s dismal record on early diagnosis of disease18.
- Episodic and preventive interventions. The rise of lifestyle diseases and personalised medicine means that preventive interventions – largely absent currently – are a vital ingredient of improvements in outcomes.
- Physical and mental health. In the mid-1950s, 150,000 people deemed to be suffering from mental health problems were housed in institutions19. By 2004/05 there were around 32,000 beds in England for those with mental health problems20. There has been little increase in community resources.
By removing these boundaries, ICOs meet the needs of a society living longer but with more conditions. This section explains the changes that will be needed if these organisations are to be created.
Removal of the health/social care split
The 1948 separation of health and social care was a mistake. Responsibility for the two systems, and their budgets, should be merged immediately. It should happen from the top down to local care systems.
A smooth, seamless patient journey
The ICO will manage best-in-class care pathways (eg from home to intermediate care facilities to hospital and back home), with each patient having one appointed case manager who will navigate them through the system21. These pathways will be made possible by a rapid introduction of electronic patient records (EPRs) set within a connected digital network.
The implementation of ICOs and EPRs have been problematic in the past. However, there have now been sufficient successes to allow implementation without multiple additional pilot studies.
A new distribution of skills
The changing epidemiology of disease means that there is a separation of expertise between two types of clinicians. There are generalists who can consider the “whole person” in their social setting – experts known as “extensivists” in the United States22. Within hospitals, advancing medical science and practice requires greater clinical specialisation. The ICO will need to be able to draw on a balance of the two.
Changing health settings
The holistic approach that modern citizens call for cannot be practised in the traditional setting of the GP’s surgery. Larger health centres are required. These should co-locate GPs with social workers, mental health experts, pharmacists and diagnostic technology.
Intermediate care/skilled nursing settings, based on an upgrading of the UK’s nursing home estate, will develop as the ICO puts the individual patient’s needs at the core of the pathway.
The ICO would also streamline 999 and 111 services so that expert assessment services are available – linked, critically, to the EPR – to improve triage of emergencies and ensure that patients are sent along the most appropriate pathway.
From treatment to prevention
The ICO is a necessary step in integrating the various strands of public health, and in delivering them in context. An important part of this shift from not only treating illness but also promoting health is a greater role for self-care.
True parity of esteem between mental and physical health
Turning parity of esteem from a political slogan into a reality is one of the core features of the ICO. The ICO will, over time, extend to the criminal justice system, absorbing the encouraging work that has been started in the UK on “troubled families”.