What is integrated care anyway?
Dr David Mummery
Every NHS era has its mantra, and in recent years this has been ’integration’. This has led to the development of regional ICS (integrated care systems) and STPs (sustainability and transformation partnerships), which now seem to be fast-tracked on the back of Covid-19.
But can someone please explain to me what 'integrated care' actually is? CCGs and NHS England can't really muster up much of a response. More importantly, hasn’t ‘care’ between primary and secondary care always been integrated? For instance:
- You would speak to a specialist over the phone for advice and then act on it;
- You would see patients following hospitalisation for review following their hospital admission;
- Community dermatology, diabetes, muscoleskeletal and numerous other specialist community clinics already exist, which have been going for decades providing excellent community care.
Patient care has and will always involve self care, primary care, secondary and tertiary care, with referral, discussions and fluidity between them. Will individuals now get ’integrated’ colonoscopies, AAA repairs and hip replacements in this brave new world? Will hospital consultants now come and do my 60 patient Monday GP on-call for me if and I go and do their rheumatology outpatients list in return? (A lot fewer patients… it’s tempting).
This is to take nothing away from nice and kind hospital consultants who occasionally do case discussions and teaching at GP practices. But unfortunately this isn’t what the ICS is really about.
Hasn’t ‘care’ between primary and secondary care always been integrated?
We can see in primary care that ’integrated care’ has nothing to do with the 'care' part of the mantra. It is in fact integrated management (CCGs and acute trusts, with lots of frequent and long meetings between the respective GP and hospital managerial classes); the start of integrated finances (cost cutting); and the gradual erosion of the independence of GPs and primary care.
It is also shorthand for pushing back large amounts of work to GPs, who hold the clinical risk as a result. This includes the almost wholesale knock back by hospital trusts of GP referrals (with the CCGs’ blessing, in many cases) and hospital letters treating GPs like they’re SHOs - lists of bloods and other tests to be done; GPs monitoring patients that should be under specialist review; letters back after triage with ‘advice’ instead of offering consultations, which have be requested by the GP.
Anyone who knows how general practice actually works knows that there is a con at the heart of the ICS project: either a patient can be looked after safely in primary and community care, or they can’t and they have to go to hospital for further tests, treatment and specialist management.
In terms of the public actually accessing primary care and A&E, the insistence of an e-consult prior to seeing a GP - and in some areas phoning 111 prior to attending A&E - may well cause major problems for patients with language problems, literacy problems or visual problems; those with learning difficulties and also the elderly.
There are, however, two things that may slow down what is happening:
Medicolegal liability: the GMC guidance on referral states that the trust receiving the referral may be liable if there are acts of ‘omission’ on their part. Hospital trusts (and CCGs) may be skating on very thin ice medico-legally speaking by rejecting so many GP referrals.
Patient choice: The rules and law about patient choice are complex, powerful and not generally well understood, and in fact rarely exercised in practice. In fact, legal rights give patients considerable power over (for example) referrals for specialist care. It is likely that a patient’s legal right for care - which NHS England and CCGs cannot impinge on - will become more important as NHS resources become tighter, and patients are increasingly denied treatment, so that NHS Trusts and CCGs can balance the books.
Yet the ICS mantra and managerial sloganning continues on. So GPs need to push back and show it to be the Emperor’s New Clothes that many of us suspected it was all along. I know it’s a cliché, but we’ll miss traditional general practice when it’s gone.
Dr David Mummery is a GP in west London and academic clinical research fellow at Imperial College London