3.3.3 Lack of Integrated Care Pathways
A lack of co-ordination between health and social care systems has led to
poorer outcomes for patients as opportunities are missed to prevent avoidable
escalation of healthcare needs. This is a particular concern for the older
population who often have long-term and complex medical conditions requiring
multiple interactions with various parts of the system. The Department of Health
estimated that people with one or more long-term condition cost NHS England
about 70 per cent of their budget but account for only 30 per cent of the
population.64
It is clear therefore that integrating care would not only improve patient
outcomes but would also save considerable money. There are already a few
pilot schemes that attempt to introduce more integrated care-in the form of
what are called Integrated Care Pathways (ICP). One such example is the two
North West London Integrated Care Pilots that cover inner and outer London
which were established in 2011. Three key elements to this and other ICP
pilots are the provision of multi-disciplinary teams, information sharing between
services and named care co-ordinators for each patient.
The North West London ICP pilot in particular improved outcomes for old
people. 77 per cent of elderly patients in the pilot were screened for their
risk of falls and 69 per cent were screened for cognitive decline allowing for
proactive discussions with multi-disciplinary teams about how to manage health
in the future. Such screening had a significant short-term impact on institutional
care with a 15 per cent reduction of non-elective admissions in those aged over
75 in 2011-2012 and a 14 per cent decrease in emergency activity in inner
North West London. It will also have a long-term impact on institution care as
88 per cent of patients in the pilot had discussed their health goals for the future
and had developed a future action plan to reach these goals and 38 per cent
of patients had started anticipatory care planning.65
Whilst this sort of approach to addressing the demand coming in through
hospital front doors shows promising results, it remains very much the exception
rather than the rule. In the future much greater use of integrated care pathways
64 Department of Health, Long
term conditions compendium
of information third edition (30
May 2012)
65 LGA, Integrated care value case
North West London, England
(October 2013)
Chapter 3 - What Is The Diagnosis? Or Why Are We Failing Our Elderly?
21
consisting of a variety of professionals from both Adult Social Care and
Health, including District Nurses, Social Workers, Community Matrons, Care
Coordinators and other specialised services, are already fundamentally closing
the 'gaps' that used to exist in service provision.
• Development of an integrated 'Front of House' - ensuring that there is
a co-ordinated approach to signposting, assessment, triage and support
management in partnership with voluntary and community sector groups.
• Transitional Care and Support to Acute Services - implementing a new,
radical approach to care categorisation, fundamentally shifting support
to home and community based support and away from the hospital.
The result has been a significant increase in the effective time spent in
delivering transitional care services, in particular reablement, and a clear
ongoing improvement in patient, client and staff satisfaction across their
communities and within the organisations involved.