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For patients, commissioners, providers and regulators, ‘joining up’ of pathways of care, delivered through integrated service models, is an essential goal.
It is refreshing, therefore, that this publication ‘Integrating primary and secondary care for children and young people: sharing practice’1 is in a format with which the children's workforce can identify and use. The paper makes reference to integrated care being ‘an umbrella term to describe initiatives which aim to address fragmentation of care between and within public services’. It draws attention to experiments which are making moves towards integration in infant, children and young people's (ICYP's) health services. It calls for investment in informed design, evaluation and research to develop a sound evidence base. Four key recommendations are made from five case studies about common foundations for innovation and change: stronger connections between paediatricians and primary care professionals, shared professional responsibility, workforce development, particularly in primary care, and new settings for specialist practice.
Despite continued advocacy and evidence for a more equitable focus on ICYP services2 these projects are not, in the main, centrally sponsored, and may be moving against the tide as implementation of the Health and Social Care Act 2012 may be further exacerbating fragmentation of care.
First of all, we examine enablers and barriers in policy and practice to develop and adopt effective integrated practice.
NHS England's Five Year Forward View recommends integrated and radical new delivery models, but focuses on elderly care services. Models of integrated care for ICYP require more extensive partnership working beyond social care to include youth justice and education systems so that ICYP, particularly with long-term conditions and complex needs, grow up to be resilient adults. Only one of 14 multispecialty community provider (MCP) model Vanguard sites is using a multidisciplinary team (MDT) approach for care planning and delivery for ICYP with long-term conditions and disabilities, within their social and home environment, and to enable their best educational attainment.
The Royal College of Paediatrics and Child Health (RCPCH) ‘Facing the Future’ series of standards3 provides both acute inpatient service standards and unscheduled care pathway standards for ICYP in primary and secondary care for commissioners, providers and regulators to use. This is against a backdrop of rising admissions for children under 5 years of age with respiratory infection and infants with feeding difficulty, and attendance rates at emergency departments are 40% higher in 2011/2012 than in 2007/2008.2
Health Education England is undertaking a system transformation project to plan for a ‘fit for purpose’ children's workforce.
The Cities and Devolution Bill may mean that health and social care budgets are devolved from central government to local councils. Effective orchestration of change is required at regional and local levels if outcomes for ICYP are to be improved.
The Strategic Clinical Networks (SCNs),4 were ideally placed to facilitate whole system transformation and improve outcomes for children. The children's SCNs could have developed their key roles (box 1), but in 2016 following a review, a reduced budget and revised SCN priorities, the children's SCNs are no longer part of the baseline budget. As a result, there is a very concerning gap as to what strategic mechanisms will be used.
The potential role for Strategic Clinical Networks (SCNs)—who will take these roles and how will these roles be taken forward?
With the demise of the children's SCNs, there needs to be an effective mechanism to:
Influence national and local policy
Learn from and influence NHS England Vanguards in their area
Be partners in NHS England Vanguard projects
Support clinical leaders and the range of stakeholders, particularly commissioners, to develop and implement whole system service transformation
Embed clinical leadership in whole system transformation projects
Support collaborative working between health professionals
Act as a conduit to share information on models of care
Promote IT and telemedicine in remote areas
Collaborate with the Academic Health Science Networks on research and other projects, and disseminate outputs
Influence commissioners and providers to use Royal College of Paediatrics and Child Health (RCPCH) and other service standards
Develop quality dashboards against a set of outcomes and use, for example, standards, audit, geographical variation in healthcare and well-being indicators
Share patient experiences, and integrate the views of children, young people and families into SCN and other quality improvement programmes through collaborations, for example, with the RCPCH patient voice platform & Us
The accompanying paper raises many issues, but we focus on four themes.
Primarily, embedding leadership and investing in team building within a robust accountability framework is a necessary foundation for change. Once in place, professionals can then ‘get on with it’ by taking on shared responsibilities for their patients. Long-term care planning can be assisted by patients and families enhancing their skills in self-care and in building their resilience, and by professionals sharing and disseminating their learning experiences.
Second, more in-depth policy research involving front-line staff and families is needed, as services are developed and delivered in innovative ways. The RCPCH is encouraging trainees and trained staff to become involved in research. It has set up the UK Child Health Research Collaboration so that funders of child health research now have an organisational partnership framework. The RCPCH is also considering ways of collating examples of integrated care models so that this information can be shared with its members and with the wider healthcare community.
Practice is often ahead of the evidence. Theory-based evaluation is a valuable approach when there is rapid and varied change. Early ‘real-time’ work to elicit core principles and essential practices can set benchmarks for stronger checks on potential interventions, and on the limits of innovation. The paper raises questions about the level of detail required to design and assess new models of care and how to make meaningful comparisons between different configurations. The paper's supplementary table suggests that some simple, shared principles can generate a significant variety of practice and so mapping variations at a more detailed level could be an important step in accumulating knowledge for practice. The paper helps to generate further questions (box 2), to explore dimensions and limits to service innovation.
Indicative questions in undertaking a more in-depth evaluation of integrated care models
What constraints are taken as absolute and which might be ‘broken’ to achieve radical change and why?
If the final outcomes are similar across all four models, for example, fewer emergency department presentations or admissions, reduced costs, or more resilient children and families, what are the mechanisms of greatest importance to each of these, or to an acceptable or sustainable balance between them?
Which data would help to monitor early progress and to evaluate effectiveness?
▸ At what stage following its implementation might any model of service reasonably be judged against the final outcomes of importance?
A third linked theme, again not new,5 but pertinent to both the Vanguard programme and wider experimentation, is about sharing experiences of the process of change from current to new configurations of services. Establishing and implementing change to services by shifting workforce resources with little new money is challenging; the learning by commissioners and providers must be shared. Successful MCP models require cross-boundary buy in, ownership by clinical and service leaders, and a collaborative mindset. Investment in project management support and backfill for clinicians provides necessary ‘headroom’ for service delivery planning. Early on, system-wide joint outcomes must be agreed, and the disincentives of payment by results and contractual arrangements need to be addressed.
Finally, the paper cites a concern among research participants that integration might result in hospital services closing. This could be a barrier but, equally, could be an opportunity. Fewer hospitals delivering inpatient care, well aligned with integrated care services (primary and secondary) delivering more care out of hospital, could be a sustainable long-term solution. Managed clinical networks (MCNs) remain to be developed for many top-end secondary/tertiary specialties, and are also required to secure effective, sustainable pathways of care across primary, secondary and tertiary care. The development of MCNs, would in part, have been a result of the children's SCNs' strategic work plans and in their absence, there is a large gap as to how quality improvement measures for children's healthcare are coordinated, implemented and evaluated—this needs to be addressed as a matter of urgency.
This paper provides valuable food for thought at local and national levels, and indicates how front-line staff can work with research organisations to conduct high value policy research through innovative healthcare service design and evaluation.
To achieve effective integrated care, fundamental systemic and institutional redesign of the organisation and resourcing of services and the children's workforce is required. Any one change will impact on other care services and challenge long-established, taken-for-granted patterns of responsibility, expertise and practice. This has to include the traditional idea of ‘healthcare’ being seen as separate from other contexts and activities through the ICYP's life course, for example, family, friendship networks, school/college, work, youth justice system. Radical system change is about revolution as much as evolution for all involved in the NHS in England, from policy development to frontline practice.
The authors thank Professor Anne Greenough Vice President (Science and Research), Royal College of Paediatrics and Child Health (RCPCH), and the RCPCH Health Policy team, in particular Isobel Howe, Head of Health Policy, for comments on previous drafts. CIE is also a clinical adviser to the Greater Manchester and Eastern Cheshire Strategic Clinical Network.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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