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Independents' Day

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

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Readers' comments (9)

  • "It is also shorthand for pushing back large amounts of work to GPs"

    Exactly. Integrated care systems are basically about shifting work into (cheaper) GP surgeries and the community compared to (expensive) hospitals.

    They're certainly not about patient care, regardless of what NHSE would have you believe.

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  • Vinci Ho

    Mottos are like movie trailers . ‘Oh yes , we love trailers’
    The Wikipedia’s definition of trailers stated ,
    ‘’Trailers consist of a series of selected shots from the film being advertised. Since the purpose of the trailer is to attract an audience to the film, these excerpts are usually drawn from the most exciting, funny, or otherwise noteworthy parts of the film but in abbreviated form and usually without producing spoilers.’’

    They are there to give you an injection of euphoria, passion , optimism and in the case of mottos a sense of righteousness. That two to three minutes eye-catching with drive of adrenaline can easily rewrite the next chapter of human history .
    The problem is , we have yet to watch the actual ‘movie’ understanding its details and complexity(or simplicity) . In fact , in many cases , the judgement and actions preceded the reality of what the mottos would entail and cost in our real lives .
    They can be morally correct like ‘United in diversity’ , ‘Only on earth’ , ‘We are the world’ and of course , lately , ‘ Black lives matter’ .
    They can be patriotic(nationalistic) like ‘ America first ‘ and ‘Take back control’ .
    They can be mythical , ‘ One belt , one road ‘ and ‘Socialism with Chinese characteristics ‘
    And they can certainly be devious , ‘Greed is good , greed works ‘ and Mao’s ‘ The more chaotic , the better ‘ .

    Our ‘Integration of Care ‘ still belongs to the first category( but perhaps mythical as well). The point is unfortunately, these mottos all fall into the trap of ‘One size fits all ‘ (which you can argue is another motto !).
    They were all generated by certain motives and ambitions which are inseparable of human emotions , part of human nature .
    So what is the reality ?
    We all want to defend our own best interests. Starting from an individual, moving onto a group and cohort ,finally reaching an organisation and institution, we are , by default , defending our territorial interests . Differences and disputes follow . May be that was a reason why globalisation and neoliberalism failed to serve their telos with a blind spot on human nature .
    Then you may remember my ‘motto’ (ha ha!)about division , discrimination, arrogance , bigotry , action/inaction against each other .
    So coming back to primary and secondary care , ‘integrated care’ is supposed to break down the barriers optimistically . Reality is the government and its subordinates are always in ‘command and control’ mode ( even before Covid 19 legislations ) . The distribution of resources was either restrictive or skewed . The government contracts with primary and secondary are distinctly different. Simply propagating the idealistic motto of integrated care without fully understanding the pros and cons , is virtually fuelling reflexive protectionism in the two camps . Covid 19 has simply escalated the narratives and generated behaviour causing resentment from both sides .
    We are all witnesses of history right now on what protectionism is doing to the world . The pandemic is really a nature call to demonstrate how its extreme form portraits .
    Last but not the least , another motto !

    ‘The pessimist looks down and hits his head. The optimist looks up and loses his footing. The realist looks forward and adjusts his path accordingly.’

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  • we should all go on holiday for 4 weeks, all at the same time, just supply all the regular scripts for that time and close shop, we deserve it. let everyone else do our job for 4 weeks and see how they manage. only way they are going to learn the realities of real life.

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  • This system can't even address a DNA. But let's audit emollients and put up bunting.

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  • I agree wholeheartedly with this analysis. Emporers. Ew clothes and brave new world are very apt analogies. We can all see it.

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  • To paraphrase a lot of letters I’m seeing:

    thanks for referring this patient urgently with symptoms that would normally require examination and investigation. When I tried to ring them today (at a time the hospital had arbitrarily chosen without checking that the patient would be able to take the call) they didn’t answer. I’m therefore discharging them, but if they have any symptoms warranting referral, please refer them to me again

    Shouts at computer and reaches for dictation....

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  • Great article

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  • Absolutely spot on ...GPs definitely treated like SHOs and everything barring cancers so easily rejected. I think the best would be to make standard refusal templates by the surgery stating:As a GP I made a referral for secondary care after making several tele and video consults and putting myself at risk by seeing this patient and using treatments to the best of my knowledge and I reject your rejection of my referral..Please contact the patient as soon as possible as there is nothing more we can offer them in primary care
    and their condition hasn't disappeared!

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  • David - you are spot on! I did ( for my sins) a intergrated care job. It was soul destroying & very management heavy. I lasted 18 months - never again!

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