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All Together Now: Is Service Integration the Revolution we’ve been waiting for?

June 10, 2013

In the world outside the hospital, a quiet revolution is taking place. It’s called Integrated Care and there is evidence that where it has been adopted, it is delivering more responsive and more streamlined community services with reduced rates of hospital admission for people with chronic long-term conditions. Meanwhile, for those of us stuck on the benighted other side of the modern-day health Iron Curtain, things could hardly be more different.

It used to be so simple. You filled a couple of sides of A4 with personal information and basic stuff about reasons for current admission, shoved it in internal post – or maybe faxed it – and basking in the warm glow of a job well done, ticked off  ‘Social Services referral’  on your to-do list. Next you heard, the allocated social worker would be setting up a meeting with the family and discussing options for discharge. Ladies and gentlemen, it ain’t like that any more.

Alongside good old Social Services, a veritable smorgasbord of agencies – Continuing Health Care, Safeguarding, Re-ablement, Palliative Care, Mental Health, Community Nursing – now form a kind of nightmare à la carte, each one demanding its own separate referral. And those referrals! They’ve expanded from my fondly-remembered two sides of A4 to something the size of a short novel.

The writing,’chasing’ and co-ordination of referrals eat up huge amounts of nursing time; progress of referrals is often poorly documented and confusing and fielding follow-up phone-calls from colleagues requesting clarification or ‘updates’ interrupts nurses during vital activities like drugs round. Isn’t it about time we started bringing the lessons of Integrated Care into the hospital?

Precise models of Integrated Care vary from place to place, but two features are consistent: the pooling of health and Social Services budgets and a ‘case-management’ system resting on ‘a single point of access for assessment and a joint care plan’ (Ross et al, 2011). From a purely selfish point of view – this sounds like Heaven. Make a single referral to a Case Manager? Sit back and let them make the supplementary referrals, liase with the patient and keep track of progress while we get on with the nursing? Fantastic! When does it start? Unfortunately, as with most things that sound really simple, a lot of hard decisions need to be taken behind the scenes.

First of all, the aims of switching to a new system within the hospital would have to be identified. Freeing up nursing time could be one, but to make the case for service redesign on this scale, there have to be others. In the community, prevention of unnecessary hospital admission is major driver for change. For patients already in hospital, this would need to translate into faster, safer discharge. Increased client satisfaction – from being able to build up a relationship with a single named individual – is also there for the taking. Financial considerations are so obvious that it’s hardly worth bringing them up.

The next question is: who should act as Case Manager? In reality, ward nurses are already acting as de facto Case Managers, but without training and without maps to guide them through a maze of agencies that just keeps growing. One approach might be to put this situation on a formal footing. The big benefit would be the potential to realise the named or ‘key’ nurse idea suggested in the Francis Report; but it would have to evolve in parallel with a major re-conceptualisation of the nursing role away from physical care and towards ‘co-ordination of care’. It might also be problematic if nurses work only a few days a week, or if patients move wards.

Another innovative idea would be to employ Case Managers who bridge the hospital-community divide – maintaining the management of their existing cases if they are admitted to hospital and taking on new cases while they are still in hospital in order to assure continuity on discharge? Because one of the most exciting aspects of Integrated Care is its potential to break down barriers and pave the way to new solutions to old problems. For example.

Integrated Care/Case Management could just provide the much-needed kick up the backside to the single area of the health service where change is most overdue: record keeping. Record keeping in large parts of the NHS – in common with much of what appears on the patients’ menus – is like a day out at the Living History Museum. Because just as, out in the real world, no one regularly eats jam roly poly and custard any more, no one in the real world regularly devotes hours of their time to the committal to paper in longhand of pages and pages of vague and meaningless ‘documentation’ – Grumbling Appendix will have more to say about this at a later date. And patients, in turn, get frustrated at having to repeat the same information to half a dozen different professionals or more. Every time they are admitted. It’s high time for all professionals to have access to secure shared electronic records.

Shared documentation – as in shared between everyone, all hospital-based health-care professionals, all community-based health-care professionals and Social Services departments and patients and carers, is essential if service integration is going to work properly. Brothers and sisters! This is the future!

Imagine if you will, a world where a click of the mouse enables you to discover that your confused elderly admission is normally mobile with a frame and only incontinent at night; that she doesn’t need to languish in bed all day bundled up in pads until her daughter visits in the evening with the necessary information; that she takes two sugars in her tea; that her care plan can be adapted to reflect the routines that are already place for her at home. Imagine a world where you are not dragged to the phone while you are in the middle of preparing IV drugs in order to assure a social worker that a patient’s condition is unchanged; imagine they can unearth that nugget for themselves by perusing the online notes; imagine a world where ‘social workers [are] authorised to spend up to a maximum of £200 per week without making further referrals’ (Ross, op cit). Imagine it – and then wake up.

The Nursing Standard last week reported that ‘nine in ten NHS leaders had made little or no progress to develop community services and integrate them with care provided in hospital’. That’s disappointing – but with all the other pressures they’re under right now, can we be surprised? There’s no sense of urgency about this.

Despite having the support of all the main political parties, the pace of change is glacial. Last year, the Department of Health published a policy document entitled The Power of Information which set out its ten-year plan for improving electronic communication in health care. Ten years? For goodness sake, we’re talking about the NHS, not a mission to Mars! The danger now is that frustrated by this slowness, local Clinical Commissioning Groups will push ahead with their own systems and the result will be local integration coupled with geographical fragmentation, as the different models fail to line up with each other. Oh well. Looks like the revolution’s on hold.

Department of Health (2012): The Power of Information: Putting all of us in control of the health information we need. London; DoH. Download at

Ross S, Curry N, Goodwin N (2011): Case Management: what it is and how it can best be implemented. London; The Kings Fund. Available to download at

Further Reading:
My article has barely scratched the surface of this hugely interesting topic.
The Kings Fund Think Tank has done much work in this area and has published a number of thought-provoking papers including the one referenced above. For a full list see:

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