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INTEGRATED CAREINTEGRATED CARE

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ISBN 978 1 906436 40 7Price: £25.00 US$45.00

EditorLeslie Paine OBE

Managing DirectorKevin Bell

Business Development DirectorJulie Wedd

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INTEGRATED CAREINTEGRATED CARE

Integrated Care

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Contents

5 ForewordLeslie Paine

PRACTICE MANAGEMENT, FINANCE ANDQUALITY ASSURANCE

6 Voice, Choice and Priority Reducing Health Inequalities – Designing Solutions forIntegrated CareSteve Feast MRCPsych, MRCGP, DRCOG, DCH,Senior Advisor, Health & WellbeingDepartment of Health

8 The Potential of Integrated CareOrganisationsDr Tim Richardson

11 Integrated Care - Attraction or Distraction?Dr David Welbourn, Director of Matrix Insight

14 Managing Change Within a Health andSocial Care EnvironmentSue Hodgetts MIHM MBA BEd MEd Chief Executive,Institute of Healthcare Management

17 Funding Models for Integrated CareOrganisationsDr Rebecca Rosen

LONG TERM CONDITIONS

19 Developing Primary and Community Care BasedPersonalised Care Plans with People withLong Term ConditionsDr David Colin-Thomé. National Clinical Director forPrimary Care. Directorate of Commissioning andSystems Management, Department of HealthDr Alf Collins. National Clinical Lead of theHealth Foundation’s Co-creating Health InitiativeDr Simon Eaton. Clinical Lead for Long Term Conditions,NHS North EastTracy Morton. Long Term Conditions Team. Directorate ofCommissioning and Systems Management, Departmentof HealthDr Sue Roberts. Chair Programme Board Year of CareProgramme and Former National Clinical Director for Diabetes

22 Improved Access to Psychological Therapies andIntegrated CareDr Alan Cohen, GP and James Seward, Director of theIAPT programme

RESPIRATORY CARE

25 The Need for an Integrated Approach tothe Care of Chronic Obstructive Pulmonary DiseaseRA Stockley, Professor of Medicine, Birmingham andR Stepney, Medical Writer, Charlbury Oxfordshire

28 Caring For COPD Patients: The Role Of Integrated CareDavid Price, Professor of Primary Care Respiratory Medicine,University of Aberdeen, and Chairman of ResearchCommittee of the International Primary Care RespiratoryGroup

30 Improving Asthma Treatment by IntegratedMedical CareNeil Churchill, Asthma UK

33 Recognising the Importance of COPDProfessor Neil Barnes

SMOKING CESSATION

36 Integrating Smoking Cessation ServicesKate Spicer - QUIT Communications Project Manager

CHILD CARE SERVICES

39 Meeting Complex Needs through Specialist Provision Matt Vince, Director, The Lioncare Group

BUILDING AND DESIGN

43 Leading the Way with Integration of Servicesand SustainabilityKentish Town Health Centre, Camden &Islington Community Solutions Ltd.

45 The Credit Crunch and Primary CareColliers CRE

47 The Right Building in The Right PlacePrimary Asset - A MedicX Group Company

Integrated Care

5

Foreword

Leslie Paine

“Integrated care,” as Professor David Price says somewhere in the following pages, “is about delivering more andbetter approaches to care and health.”

Fifty years ago the watchwords of the stripling NHS were “Putting the Patient First”. Today, the call is for Integratedcare that crosses boundaries - primary and secondary; health and social; local and national - and recognises thatessential members of its Care Team are the people who have the greatest practical knowledge of the conditionwhich the team is addressing - the individual patients.

As Dr Steve Feast points out in his article on “Reducing Health Inequalities - Designing Solutions for IntegratedCare”:

“What is required is to engage with those who find it hardest to influence change, and then to give them thevoice and authority that translates needs into socially and culturally competent services.”

In other words, putting the patient, no matter how lowly, not just first, but at the very heart of the picture. AsDr Feast infers, it is not particularly difficult to produce glossy reports identifying where needs exist and which needsare the greatest. Indeed, he believes that such productions are the stock in trade of many health professionals. Buttheir productions are of no help to sick or disadvantaged people unless they have direct beneficial results. Aboveall else, integrated care solutions must produce appropriate, practical benefits for those in receipt of the care.Otherwise they are just a waste of time.

Such solutions do not necessarily have to be directly clinical of course. In the pages that follow, you will findreports of integration being created by new organisations (like Dr Tim Richardson’s “Epsom Downs Integrated CareServices (EDICS) Ltd”); by managerial action (Sue Hodgett’s “Managing Change Within a Health and Social CareEnvironment”); by financial mechanisms (Dr Rebecca Rosen’s “Funding Models for Integrated Care Organisations”);and by the design of health and care premises (The Kentish Town Health Centre: “Leading the Way with Integrationof Services and Sustainability”).

Nevertheless, those programmes that are likely to impress patients most are the ones where new forms ofintegrated care directly improve some aspect of the condition from which they suffer.

Take, for example, those many people who are plagued by long term conditions and have complex health andsocial care needs. Two recent national initiatives in integrated care are of considerable importance to them - theGovernment programme for individual, personalised, primary and community care plans for each and every one ofthem; and the new service which offers improved access to psychological therapies (IAPT) to all who suffer fromcommon mental health problems. Articles by Dr David Colin-Thome, National Director of Primary Care et al; andDr Alan Cohen GP, and James Seward, Director of the IAPT Programme; review both of these developments insubsequent pages.

Other conditions similarly covered in this publication include Chronic Obstructive Pulmonary Disease (COPD)(Professors R A Stockley and David Price); Asthma (Neil Churchill, Asthma UK); Smoking Cessation (Kate Spicer,QUIT); and Cardiac Care (Echo Services Ltd). Although as Professor Price reminds us - “No single model of integratedcare will work for everywhere since it depends on local circumstances”. ■

Integrated Care

Practice Management, Finance and Quality Assurance6

Voice, Choice and Priority ReducingHealth Inequalities - DesigningSolutions for Integrated CareSteve Feast MRCPsych, MRCGP, DRCOG, DCHSenior Advisor, Health & Wellbeing Department of Health

It is a sad fact that those communities that experience theworst health outcomes too frequently also have the lowestaspirations for improved health. Many adverse health

behaviours can become normalised locally, with people unwillingor unaware as to how to challenge the existing unhealthy statusquo. Their available range and supply of, and opportunity toengage with, health improving opportunities may also be few.This compounds through the low levels of local social andgeographical mobility that is typically much lower than in moreaffluent communities, locking in intergenerational experiencesand low aspirations for change. The challenge therefore forhealth and social care planners and investors is - how do we usepublic services not just to provide the essential services for thosewho are already ill - but to engage in a dynamic tension withlocal communities and their leaders which will help drive upaspiration and desire for change and improvement? How do wehelp work through community assets and create a local socialmovement for change?

It is relatively easy to use existing data sets to map and identifywhere community needs are likely to be greatest. Indeed,triangulating data and translating these into glossy reports andpower point presentations is the stock in trade of many healthprofessionals. However, it is much harder to reach out and getone’s metaphorical hands dirty by proactively seeking those whosevoice we seldom hear. What is required to engage with those whofind it hardest to influence change and then to give them the voiceand authority that translates needs into socially and culturallycompetent services?

Frequently those who need our help the most are commonlylabelled as hard to reach, or it is reported that they can only bereached with greater effort or expense than is needed to get tothe more affluent who use services ‘more appropriately’. However,in other spheres of their lives utility companies, illicit tobaccosalespersons and recreational drug dealers find them relativelystraight forward to find and engage. We must seek out andengage with those who need public service help the most at theirconvenience - not at the convenience of those who provide theintegrated services.

Once people have become engaged in helping to define theirneeds, there are now many exciting ways whereby we can assistindividuals and communities in the co production of the myriad ofsolutions that will help engage and motivate people’s ability toimprove their health and wellbeing, and start them down a pathto improved outcomes for all. These include how we can empowerlocal people through influence over resources; how we plan the

services they receive and how we optimise clients’ flexibility andchoice at the point of delivery.

Any assessment of local need should also include an assessmentand audit of the positive assets that surround people and with andthrough which they are more likely to engage. It is too easy todamn a local area with statistics and facts that miss out the verymany positive community assets around. As we build and designintegrated care solutions we must be mindful of what alreadyexists, its heritage and characteristics, and seek to work throughthese assets to design and deliver what it needed. Many existingcommunity groups have a heritage of local provision. Localcommunity leaders may be the right people through whom toengage young people and intergenerational alliances caneffectively break down local cultural barriers. All these should bebuilt where feasible into new integrated care approaches.

Commissioning is the best tool we have to use in the systemreform box and we need to apply it expertly across public servicefootprints to develop an integrated investment approach. Localpublic services now routinely share data and information throughtheir common joint needs assessments. Local authorities alsopossess lots of information and intelligence gained through theirmembers, engagement structures and functions. Commissionersshould triangulate this soft and hard data in order to build up agood picture of a local community’s assets and deficits, using thisto prioritise investments. Each community has its own uniquecharacteristics - how do we respect these and build upon them?What Third Sector providers already exist and what additionalintelligence do they have that commissioners can utilise and betterunderstand the needs of the client group in question? How doesa Third Sector investment plan develop local community capital?

A lot of the solution starts by basing the services and the peoplerunning them right in the heart of communities. This may requiresome hard bargaining and discussion, as local land prices may behigher in more densely populated areas. However, it is not goodenough to site services in out of town locations where those mostlikely to need them are in reality least likely to access them. Manynew health centres sit proudly on the edge of out of town estates.The local commissioners who built them on the readily availablecheaper land then have to try retrospectively to mitigate the impactsof poor planning choices through constant fruitless dialogue withlocal transport providers. It would be much better to site thesolution in the centre of the town or challenged community in thefirst place. Locating services where people can access them andfrom which the staff based within them can easily outreach, alsoreduces many long and wasteful journeys between clients.

Integrated Care

The empowerment agenda offers huge possibilities to helpchannel resources through individuals and communities co-investing in the local fabric of support through social and familynetworks. Local community indicative budgeting and individualbudgets are the participatory commissioning tools of the future.Social care individual budget pilots have taught us a lot as to howpeople can responsibly and effectively use and access resources toimprove their care solutions. Those designing integrated careservices should look and see how they can best support anddevelop a multi channel set of products that engage those at needas much on their terms as on those of the service provider.

It may not be affordable to support a wide range of separateintegrated care providers locally but it will almost certainly beaffordable to develop a set of different products within eachprovider envelope, which will better engage with a wider range ofclients’ needs. This especially relates to the ‘add on’ and wrap-around services that help reduce the future ill health effects thatpeople’s current lifestyle choices present. What range of smokingcessation or alcohol harm reduction advice and services are availableand how do they link to the local Health Trainer services? Whatexercise options are we offering the elderly clients to reduce theirfuture risk of dementia? There are many ways existing staff andcapacity can be trained to provide additional lifestyle support thatresets the local defaults, challenges the prevailing norms and makeschallenging unhealthy lifestyles the new norm not the exception.

At the end of the day, it is providers not commissioners who aremost likely to innovate. They do this when trying to achieve theoutcomes that commissioners have specified as desired within thecost envelope available. The onus is therefore upon commissionersto be clear what the outcomes are that they want to specify andcommission against, challenging providers to meet them. Thenproviders will have more freedom to innovate and moderniseservices working through an outcomes based process. This is nota one hundred and twenty-page contracting process that stiflesinnovation - it is a much shorter and clearer set of specificationsthat are set up alongside the metrics and measures that will reportprogress and achievement of the outcomes commissioned against.

A good needs assessment process will have identified whatunmet needs matter most to local people. Local existing and futurepotential providers should be invited to add to this knowledge andintelligence based upon the data and information they hold aboutclient groups, further enriching commissioner intelligence. Publicservice commissioners then triangulate this data formulating it intoa clear desired outcome and an hypothesis as to how unmet needswill best be met. At this point they can re-engage with theproviders agreeing how best to secure delivery through a pluralsupply market. This will become the hallmark of our bettercommissioning systems.

Finally, those who are the least articulate and frequently poorestat advocating for change are also those we should most carefully

work with to check that the needs commissioned against haveactually been met. What processes have providers got in place thathelp those whose first language is not English, or for those whoare illiterate to report whether they are satisfied with the serviceprovided? How is continuous feedback being used and developedto refine the service offer? Did the service actually meet their needsor are they still using an alternative more expensive option at thelocal A&E as well as what is now offered in parallel?.

Commissioning integrated care solutions has great potential tohelp close existing gaps in health inequalities and to raise localaspirations for better health. Well-designed culturally competentservices are most likely to address need. Making these solutionseasily accessible and based within the heart of communities forthose who need them the most, addresses not just access issues -but also through great design and local engagement - can helpraise community esteem and address issues of poverty of aspirationand desire for change. In a period of economic turndown, howpublic services deploy capital, purchases and procures, employsand trains is really going to matter to those in lower socioeconomicgroups. We can use the development of integrated care solutionsto drive wider societal improvements that will further empowerthose who need our help the most. ■

BIOGRAPHYDr Steve Feast works as a Senior Advisor in Health &Wellbeing at the Department of Health and is currentlyworking within DH and across other governmentdepartments on projects relating to health inequalities,commissioning and incentives. In this role he was theHealth and Wellbeing Lead on the Our Health, Our Care,Our Say White Paper and the Commissioning Framework forHealth and Wellbeing. Recently Steve co-developed thecompetencies for the World Class Commissioningprogramme. For 16 years, Steve was a partner in generalpractice and was formerly a PEC Chair in Bedfordshire.

Prior to appointment to the Department of Health, Stevewas Clinical Innovation Director of the NHS ModernisationAgency. He has also worked as the National Lead PEC Chairat National Primary and Care Trust development team andas the PCT advisor to the CHI Star Ratings team. As PCT Leadin the Healthcare Commission transition team, Steve helpedlead the design of the new system of assessment thatreplaced Star Ratings.

Practice Management, Finance and Quality Assurance 7

Integrated Care


The Potential of IntegratedCare Organisations

Dr Tim Richardson

WHAT IS INTEGRATED CARE AND WHAT IS ANINTEGRATED CARE ORGANISATION [ICO]?

ICOs are a new concept in the United Kingdom which has devel-oped from the difficulties of making Practice Based Commissioning[PBC] an effective tool to redesign health care services. ICOs are nota new concept elsewhere and in particular in parts of the USA theyhave been in existence for many years. The best known is the KaiserPermanente Health Maintenance Organisation [HMO] initiallyfounded in Southern California but spreading through Californiaand the West Central states in the USA.

The ICO concept is the provision of all necessary health [and insome cases associated social] care through a single capitation pay-ment by the payer [government in the UK] to a single responsibleand comprehensive provider organisation. It could be argued thatthis is just what the NHS should have been but with parliament vot-ing separate funds for primary care services and for hospital/com-munity services together with separate [and means tested] socialcare funding divided between national and local government meansthere is no single capitated sum, per individual, identified. Further-more the provision of services has been by multiple, often compet-ing providers with individual rather than collective organisationalresponsibilities and thus a large measure of self interest which does-n’t foster effective collaboration.

Thus it is hardly surprising that individuals needing care have lit-tle understanding of the care services systems and how to navigatethem and thus why their care is fragmented, inefficient and often farless clinically effective than is achievable. What is missing is wholepatient complete care responsibility [financial and clinical] by a sin-gle provider and thus fully co-ordinated care planning and delivery.

The piloting and development of ICOs in England is an attempt toidentify a single responsible provider to manage all aspects of an in-dividual’s health needs for an agreed capitated sum, initially usingNHS funding but eventually merging elements of social care fund-ing as well. Currently the whole devolved NHS spend comes intoGPs’ PBC commissioning budgets but this is a nominal sum held bythe Primary Care Trust [PCT] whose responsibility it remains and overwhich the GP has neither autonomy or direct financial responsibil-ity. It is now over 4 years since this government reintroduced pri-mary care commissioning, PBC, having scrapped successful GPcommissioning in 1999.

The ICO offer now is for GPs or organisations holding registeredlists of patients to take their fairly allocated share of NHS patient re-sources under a managed care [provider] contract as the single re-sponsible care provider, rather than nominal commissioner, anddeliver or plan and procure the full range of healthcare that patients

need. The perceived benefit is that one total budget will produceone co-ordinated healthcare team across primary, hospital and com-munity services offering whole pathway planning to deliver best careat the most efficient cost. As the contract would be an ongoing orrolling contract for the registered population similar to current GPcontracts and as the surpluses and overspends would become theresponsibility of the ICO provider, so the financial balance would notbe the overriding priority which has led UK healthcare to be led byaccountants rather than professional managers or clinicians.

EXAMPLES OF INTEGRATED CARE IN ENGLANDThe result of a single “at risk” budget sum [the contract value] held

by a management team led by clinicians would be the developmentof more effective and efficient clinical pathways and greater real in-tegration across the various tribes of current healthcare. This hasbeen happening as a result of the Primary Care Act Pilots [PCAPs]started in 1998 which resulted in a new GP contract called PrimaryMedical Services [PMS] moving willing GPs from part 2 of the NHS actto part 1. There, as well as contracting to deliver general practiceservices [PMS], they could also contract to deliver hospital and com-munity type services under PMS Plus contracts which practices thatremained within part 2 of the NHS act as GMS practices, could not.

From 1991 to 1999, when New Labour scrapped it, GPs had theright to hold purchasing budgets to buy hospital and communityservices for their patients. The more recent PBC initiative wasmeant to replicate this but PCTs haven’t effectively supported thisas it was intended. Practices such as my own used our fundhold-ing budgets not only to buy services but increasingly transfer morecare from hospital to within our practices with other more experthealthcare colleagues coming on site to work collaboratively withus. Technically however we were not allowed directly to provide

Dr Tim Richardson

Integrated Care

these services as they were part 1 NHS services and GPs were part2 NHS contractors.

The last conservative government understood that GPs needed tobecome providers of such services in their Primary Care Led NHS,rather than commissioners which is what they were as fundholders.Thus they passed the Primary Care Act [PCA] in April1997 with sup-port from the soon to be New Labour government which allowedGPs to move to part 1 of [the original] NHS act, becoming PMS prac-tices, under the PCA pilot, and so contract to take on the part 1services they wanted to deliver rather than purchase under fund-holding.

This opportunity was supported and taken up by many prac-tices. We merged with 2 other practices to create the IntegratedCare Partnership in April 1998 and take on both a PMS GeneralPractice contract and a comprehensive PMS Plus contract for awide range of other services as the formally contracted providerto our Health Authority. These were services which we had al-ready set up having previously purchased our local old cottagehospital and modernised it to Healthcare Commission standardsincluding the first fully Independent Freestanding Day Surgery fa-cility in the UK.

The services we contracted to provide included;• Direct access therapies including physiotherapy and podiatry • Advisory services such as dietetics • Imaging diagnostics including plain x ray, ultra sound and an

MRI budget for direct GP referral• INR services• A wide range of specialist clinics with GPs, practice based spe-

cialist nurses and therapists supporting visiting specialists in allthe major specialties.

• Direct access endoscopy and a full range of day surgery proce-dures

• End of Life care and the medical management of in patients inthe newly built Cottage Hospital

• Community nursing services• Medicines management within in an “at risk” financial enve-

lope, even though this was at below both national and local av-erage medicine spends.

We also jointly ran an extended GP and OOH service with neigh-bouring practices staying open to 10pm 364 days a year whichclosed with the end of 24 hour GP provision and the centralisationof OOH by the PCT. During this time we had the lowest A&E atten-dances by practices and far fewer acute admissions especially theshort stay admissions that result from the 4 hour A&E discharge tar-get. Re-introducing this or siting a GP service at the front door ofacute hospitals would be a natural extension of Integrated Care,working with the acute sector to triage patients to the most appro-priate service for their immediate needs.

In all these services we were either directly employing new staff ienurses, radiographers and physiotherapists and either secondingfrom hospitals or directly contracting in specialists to do clinics andoperate on appropriate patients on site.

Thus we became the contracted Integrated Care provider for mostof our elective and chronic disease pathways and for much of ourolder patients’ non acute needs. We didn’t however have a notionalcommissioning budget until 2007/8 so no overall population finan-cial spending target. However against the equivalent HRG levels ourprices were up to 25% less and we estimate we were saving the PCTover £ 500,000 annually on elective care for our 24,500 patients.

FUTURE DEVLOPMENTSWith our experience of both Integrated Care provision and com-

missioning, we were pleased to hear in 2004 that primary carewould be offered budgets again albeit through PBC. When it be-came apparent that PCTs were either unable or unwilling fully tosupport this initiative and that the budgets were only notional withno management funding, activity data or regular reporting, enthu-siasm for PBC waned and the expected engagement and benefitsdidn’t happen. Furthermore with full financial liability remainingwith the PCT it was hard to see PCTs letting go of responsibility un-less GPs were willing and able to take on financial risk as a con-tracted managed care provider which is what ICOs are expected tobe. Thus we made the offer to take on this risk over 2 years ago butat a time of PCT mergers and disorganisation which has only justbegun really to settle.

We joined with other practices from a wide but not totally co-ter-minus area, keen to be more actively engaged in taking manage-ment control of their patients’ services and willing to explore therisks of managing within a fixed financial sum. This entailed a de-tailed analysis of activity and the modelling and costing of expandednew integrated care pathways and out of hospital services of whichwe had good prior experience and sound costings resulting fromour integrated care PMS plus contracts.

To do this and secure the management expertise and access to realcapital, we realised the need to work with a “world class healthcaremanagement organisation” which took just over a year to find. Weeventually selected Integrated Health Partners led by a former Kaiserhead of neurology trained in London who had spent 6 years devel-oping McKinsey’s healthcare consulting practice and then set up hisown well capitalised company to support GP practices wanting tomove into total budget responsibility. We have worked together for18 months carrying out full and detailed data analyses on all our in-terested practices, comparing and contrasting performance andmodelling ways jointly to re-engineer care pathways at lower costbut with greater levels of clinical co-ordination and cost efficiency.This model has been adopted by other practices and is being pre-sented to PCTs as an alternative to PBC to achieve GP engagementand start transferring levels of budget risk from PCTs to primary care.


Integrated Care

The development of the national ICO program was preceded bysuch a pilot in Surrey but the 2006 PBC guidance already allows thetransfer of PBC commissioning activity from PBC budgets into prac-tice level provider contracts similar to the development of PMS pluscontracts. In fact PMS plus still exists for practices and willing PCTsto use and the concept has been extended into multipracticeprovider contracting through Specialist PMS [SPMS]. Here too wepioneered the first multipractice SPMS contract in 2005 where ourlocal practices formed a multipractice company Epsom Downs In-tegrated Care Services Ltd [EDICS] which has contracted on behalfof all the practices’ with the PCT to deliver a wide range of primarycare specialist out patient services in the community. This has, likeour PMS plus contracts led to closer working between the practicesand the local acute hospitals and their clinicians and will be extendedthrough the developing ICO concept to cover all elective care andchronic disease pathways initially and onto the GP front door to A&Eas well as managing a rapid diagnostic service to take over from themedical assessment unit where each attendance is counted as anadmission even when patients only require advice.

RELATIONSHIP WITH SOCIAL SERVICESIn the long run there will be an increasing need to integrate health

and social care and its funding but this is difficult whilst healthcareis free at the point of service and social care is means tested. Thereare many care services which require both health and social inputsfrom children’s services to dementia care and there are already manyinstances of very close and effective working without formallymerged budgets. For many children’s services health budgets arebeing transferred to social services to manage on an integratedbasis. Transferring budgets the other way is far more difficult be-cause of the means testing requirements which healthcare providershaven’t faced before. Further work needs to be done politically toachieve effective shared resources that will formally bring health andsocial care professionals into a single integrated team

SUMMARYTo achieve the most effective use of tax payers’ money and im-

prove health through better preventive measures as well as delivermore effective and seamless healthcare it is recognised that currentcontracting and delivery incentives, including PBC, are not working.Thus the next development is the creation of Integrated Care Or-ganisations to hold the whole health and possibly social care budgetbut as a managed care provider rather than as a pure commissioner.Funding would be based on registered patients on an annual capi-tated basis with actuarial adjusted capitation amounts reflectingage, sex and existing [an possibly predictive] diseases reflecting theirhealthcare needs.

Such organisations would include general practices most likelywith expert healthcare management partners providing IT manage-ment and monitoring and risk and development capital based on

well developed internal health needs assessments and commensu-rate business plans.

Integration is likely to result with horizontally [practices eitherworking together or merging], and between practices and commu-nity services, both nursing and eventually social care and verticallywith hospital providers and their clinicians. To achieve these singleresponsible provider organisations and the integration that shouldresult requires not just government pilots but PCT support and drive.To ensure this happens we need to see a rapid wave of early imple-menters fully supported at both national and local level. Where PCTshave other agendas and block progress the Department of Healthneeds to step in or accept another well intentioned and good initia-tive will be wasted along with millions more of tax payers money. ■

DR TIM RICHARDSONDr Tim Richardson initially trained as a Navigation Officerwith the P&O Lines. He went to medical school at StBartholomew’s Hospital, London, in 1973; obtained his MBBS in 1979 and became a member of the Royal College ofGeneral Practitioners, London, in 1983.

That year he also became a Principal in General Practice inEpsom and 7 years later in 1990-91 led the Practice’sacquisition of the Old Cottage Hospital (OCH), Epsom. Hebecame Lead GP for fundholding [practice budget] 1991 andTotal purchasing pilot in 1996-99.

In 1994 he set up the first independent diagnostic andtreatment centre (DTC) called Epsom Day Surgery, in theEpsom Old Cottage Hospital, and has managed it since1998. That same year he was involved in the merger of threepractices to form the Integrated Care Partnership (ICP)which became a first wave PMS plus practice. ICP providesthe widest range of services by a single NHS practice,including general practice, therapies, diagnostics such asplain xray, ultrasound, direct access endoscopy, specialistoutpatient clinics, and a wide range of specialist day surgeryand chronic disease management including ‘in patient’community hospital care.

He was instrumental in setting up the first GP SpecialistPersonal Medical Services (SPMS) company in 2006. This isEpsom Downs Integrated Care Services (EDICS) Ltd whichmanaged all their GPs’ specialist referrals, moving themajority of Primary Care Centres closer to patients. Also in2006, he set up a second independent diagnostic andtreatment centre (DTC) called Cobham Day Surgery in theCobham Cottage Hospital (CCH).

He is a member of the executive of the NationalAssociation of Primary Care and of the Department ofHealth Forward Thinking Strategy View Group.

He is currently working on a managed care model todevelop integrated clinical services.


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Integrated Care -Attraction orDistraction?Dr David Welbourn, Director of Matrix Insight

Better integration between primary and secondary care,health and social services, development of “integrated carerecords” and the establishment of “effective multidiscipli-

nary teams”, have been recommendations in Enquiries and objec-tives in business plans for many years. It is nothing new, but whilstsome organisations, agencies and professionals see the focus onintegrated care positively, others see spending valuable time oninitiatives to support care integration as a distraction from the realissues of the day - one to one care, finance, and targets. Bothresponses are natural - work pressures, limited time and moneymean that selling and delivering the real value of “integrated care”is challenging. This article focuses on the real improvements thatcan be achieved through better integration, bringing in evidencefrom other industries, and what can be done to support delivery.

THE MOTIVATION FOR INTEGRATIONIntegration is not a requirement for the delivery of good care, or

even a good experience of care. Rather, appropriate and effectiveintegration is one of a number of ways in which the highest qual-ity care can be delivered, providing a better experience, andbetter outcomes - it is a means to an end, rather than an end initself. It is equally true that a model of care which has been de-signed to achieve integration as a primary requirement can missthe point completely, leading to some of the least effective care.

The rationale for this is similar to that underpinning the applicationof lean methods, and business process re-engineering in the1980s, which are being seen by many organisations as thepanacea to solve all ills (see inset panel).

This difference in emphasis is similar to that between specifica-tions which are input-based versus those output-based. No-one inthe system design business would now promote an input-basedspecification in preference to an output-based specification.Despite this inferiority, many system designs still adopt the olderapproach, through a combination of inertia and lack of relevantexperience. The same is undoubtedly true in healthcare. The temp-tation remains strong to specify care based on the assumed ben-efits of integration, rather than allowing the focus to remain firmlyon those requirements which define good care. Put at its simplest,any healthcare system should be designed to meet the underlyingpriorities for good care, not simply follow an assumption thatintegration is best. These genuine requirements must assure highquality and safe outcomes, a good experience for the service user,and all delivered efficiently to achieve good value for money.

THE VALUE OF INTEGRATIONHaving positioned integrated care in this way, it is worth taking

another detour to look at potential learning from the electronicsindustry. The inset describes the benefits that integration hasbrought to that industry, showing that focus on the underlyingenablers is critical to success.

This analogy suggests that we should concentrate our attentionon similar enablers in healthcare:

• elimination/ reduction in boundaries and handoffs;• greater quality, reliability, consistency and repeatability in

performance;• more effective relationships from co-location and closer

inter-working across multi-disciplinary teams;• better use and sharing of information;• better efficiency and value by reducing waste.

For world-class healthcare, it is clear that this list sets out thecritical ingredient of success, measured by better patient/serviceuser experience, better outcomes, greater safety, reduced inequal-ities and better value. They also directly support a culture in whichcare pathway design embraces full involvement of multiple pro-fessionals and best evidence. Furthermore, enforcement of goodprocess control ensures that optimally designed pathways areroutinely followed.

There are many technical components and operational meth-ods which identify a lean system, but I have always foundthe most help in a broader, more philosophical viewpoint.

From this perspective, the essence of a lean system is onewhich is built with the customer experience and product orservice quality as the pivotal design principle, with owner-ship and responsibility for quality and experience vested inthose right on the front line. It is this combination of focusand ownership which drives the passionate focus on elimi-nating waste, thereby achieving strong financial results. Thisneeds to be contrasted sharply with a system whose mainfocus is to control finances, which can so easily lead todecisions dominated by crude monetary measures, drivingthe wrong decisions and ultimately delivering poor value.

The very simple message is that best results are achievedthrough an outcomes focus, not by controlling inputs.

Lean Systems

Integrated Care

Like all analogues, we must avoid stretching the analogybeyond reason. It clearly fails to address the importance ofculture, ownership of patient care and compassion. Key ingredi-ents in world-class healthcare must generate a real sense thatcare-providers fully own the whole, seamless experience, firmlycentred on the patient, with a clear aim to achieve highest qual-ity outcomes. This culture must generate trust and confidence,not just a technical specification. As with the other ingredientsalready discussed, these are strongly supported by integration ofcare, without necessarily being delivered successfully by everydifferent model of integration.

INTEGRATION IS NOT ENOUGHOther factors also play a strong part in achieving best care, for

which integration does not naturally offer help. As demonstratedby experiences from other industries, there needs to be increasedemphasis on openness to new ideas and change as critical enablersfor improvement. Maintaining care at the forefront of evolvingbest-practice requires this openness in order to encourage:

• innovation and its adoption;• evaluation and critical peer review (e.g. clinical audit); • linking research, teaching and delivery.

Openness can be stimulated by the challenge of competitionand plurality of supply, but there is a possibility that integrationcan discourage these. A poorly designed approach can lead toexclusivity instead of inclusivity. Stagnation and ossification are thedangers which could arise from treating integration as a primarydriver. By focusing on the real drivers, this risk is readily exposedand pathway designers can take effective steps to ensure thatreview and openness are built into the solution.

DIFFERENT MODELS OF INTEGRATIONTaking integration further, it is clear that there are several

approaches to integrated care.The vertically integrated model of care recognises that

quality of care can be improved by bringing together the differentstrengths of primary, community and secondary care. This involvesa new model of care effectively integrating the different skills andapproaches into a single team. Generally, this requires co-locationof the different professions, working to shared objectives, operat-ing in a single management/ governance structure - an integratedteam. A typical application would be in a primary and urgent carecentre, drawing together the hospital emergency department, out-of-hours provision, general practice, and community services (bothhealth and social).

Practice Management, Finance and Quality Assurance

The electronics industry has arguably been the most successful over the last half century. It touches every part of life inthe developed world and is helping emerging economies to accelerate their development in new and exciting ways, oftenleapfrogging their developed counterparts in exploitation of new, better solutions.

Why has it been so successful in transforming the way we think, the things we do, and the tools we use?

From the first laboratory transistor in 1947, to the first fully integrated semiconductor in 1958, all the way to the latestmicroprocessor with over 2bn transistors compressed into a space smaller than that 1947 transistor, the industry fervour hasbeen fuelled by integration. This has delivered enormous new capability, opening previously undreamed of applications andsolutions. Moore’s law which states empirically that memory capacity doubles every 18 months has been closely followedthroughout this whole period. But integration is not the root-cause of success. True success has come from importantdrivers which integration has been able to exploit:

•better production techniques reduce defects, giving higher success rates; •reduced variability allows tighter design tolerances, permitting less stressful operating conditions;•unnecessary interfaces and handoffs are eliminated, reducing failure rates;•more predictable relationships across the system improves consistency of outcomes;•transaction times, data transfer times and shared use of data are all tightly controlled and predictable;•advances in manufacturing have enabled co-location of components from different disciplines (technologies and functions).

These drivers have been described in a way to illustrate benefits, using terminology consistent with that used in thehealthcare industry. This shows that, in essence, the technology advances which enabled greater integration for the electronicsindustry, also lie at the heart of better health outcomes, more consistent experiences, and greater value.

Integration in the electronics industry

12

Integrated Care

In horizontal integration, the emphasis is placed more on dif-ferent professions working closely together to maximise continu-ity across the boundaries, but with each team generally retainingdistinct responsibilities. Each part of the integrated team will tendto retain its own identity, with clear positioning within an overallidentity and common vision, purpose and goals. In this approach,patients will generally spend discrete periods within sub-teams,whilst benefiting from coherence and consistency derived from theshared agenda. This works well for clinical networks and shouldoffer good continuity of care at the traditional step-up and step-down boundaries.

Each of these approaches can reflect integration at process (orpathway) level, or can be more structural, leading ultimately toorganisational integration. As already discussed, both strengthsand weaknesses of integration are affected by the flexibility andsense of permanence created by the integration. At its extremes,organisational integration of public services requires legislation toaffect major change, and can therefore be unresponsive, whereasprocess integration can lead to weaker commitments and solu-tions which are less resilient. Strong governance, management anddecision-making processes generally provide the most reliable keyto manage either extreme of risk.

CONCLUSIONThere is no doubt that increased integration has the potential to

contribute significantly to the continuing transformation of care

delivery, emphasising quality, outcomes and experience. To achievethe very best from integration, it is not sufficient to see it as anend in itself. Instead, it is vital to understand what drives itssuccess and to give greatest consideration to these enablers whenselecting a particular approach to integration. ■

THE AUTHORDr David Welbourn is a director of Matrix Insight, a formerstrategic health authority Director of Performance and ChiefInformation Officer. He was also Chief Operating Officer inthe start-up phase of London’s Commissioning SupportService. He has worked in system design, changemanagement, strategy and corporate governance.A chartered engineer and physicist, he began his researchcareer in the semiconductor business, gaining numerouspatents in the early 1980s stretching the boundaries ofintegration, reliability and performance.

Since joining Matrix he has led many service review andtransformation projects, including design and developmentof both vertical and horizontal integrated care models,particularly emphasising the co-creation of stronggovernance models.

For more information please visithttp://matrixknowledge.com/


Requirements for Good Care

Integrated Care


Managing Change Withina Health and Social CareEnvironmentSue Hodgetts MIHM MBA BEd MEd Chief Executive, Institute of Healthcare Management

Icould go a lot further back, but if you look at the past 8 years -starting with the NHS Plan in 2000, and at all of the changesin Social Care - there has been an over dependence on change

as a means of driving delivery.

The three stages of NHS reform are:

• Building capacity in the system• Introducing reform levers• Transforming the system

The final stage is being enforced by the current Prime Minister.“We need to listen to patients’ experience and expectations toforge a new partnership with (Health and Social care)practitioners” (Gordon Brown, July 2007).

There are positive arguments for reform and the need forreform in an ever changing landscape of health and social care:

• By 2015 there will be a quarter more over 85-year-olds, needingboth complex health and comprehensive personal care;

• The cost of new drugs is increasing;• There are new diseases of a modern lifestyle including obesity

which require an integrated approach across sector andorganisational boundaries;

• An increase in diabetes and other long term conditions alsorequire a community approach;

• Above all there are rising expectations from our consumers -patients, carers and public, who are more informed, wanting24/7 access and a high quality of care.

Unfortunately, inequalities still exist and often the poorestpeople have the poorest healthcare. So creating a self sustainingHealth and Social care system with safe and effective services,improved user experience, equality of experience and outcomes,innovative approaches to care and making the best use ofavailable funds is a challenge across all sectors.

To achieve these expectations there needs to be, not only aneffective use of available resource, but more importantly effectivepeople management that will lead to this improved patient care,improving health and well-being that support independence andan improved quality of life. The service needs to be responsiveand have accessible services that treat people with respect andgive users control and choice. It is a tall order!

There are overt incentives that will drive improvements inhealth and social care, these are organisational rather than

individual incentives; there are rewards such as payment byresults and matching of the quality and outcomes frameworksas well as meeting local and national targets.

Improving capacity and capability by using different providershas become common practice, and to ensure success requiresgood governance across organisations. Implementing serviceredesign, improving education in the workplace and introducingrelevant accreditation, particularly for management also wouldcontribute to improving the service we offer patients / clients.Celebrating improved responsiveness from patients, clients andpublic through incentives such as Choice, commissioning,guidance, national awards rewards the hard work of staffcontinually managing change. So the incentives to driveimprovements in local health services should lead to betterquality, better patient experience, and better value for money aswell as equality of experience.

None of the above outcomes happen through chance or luck. Itis about effective people management. Motivating individuals toachieve organisational success and see it as their successfulcontribution, requires a certain relationship with both individualsand teams.

Sue Hodgetts MIHM MBA BEd MEd

Integrated Care

Establishing a psychological contract between the individualand the organisation is vital. Creating an understanding aboutcommon values and goals can be reinforced throughmanagement style and transparent ways of working.

Individuals and teams need a commitment to work towardsagreed objectives, understanding and agreeing with the rationalefor these objectives is essential.

Acknowledging and celebrating these achievements will bemotivating in itself. And seeing the benefits of the achievementsfor patients and staff will add to staff commitment.

The identified reform, whether it was “The NHS Plan”,” TheNHS Improvement Plan”, “Our health, our care our say”,“Options for the Future of Payment by Results”, to name but fourof the possible 10 white papers that have landed on the desks ofNHS and Social care Boards in the last eight years have indeedhelped to direct change. But, the delivery of the expectedoutcomes is dependent on the competence of both clinicians andmanagers and their teams and their ability to work withindividuals, teams, organisations and across organisations toensure integrated pathways of care.

Historically, the NHS has been notorious for its ‘command andcontrol’ style of management with its top-down approach, tellingrather than asking, being task obsessed and driven by targetswhich may have missed the point.

I do believe things are changing. Many organisations aredeveloping a culture where the concerns of patients and staff arethe driving force of the business rather than constantly reactingto target-driven reforms handed down from central government.

There is an emphasis on engagement and clarity about values.Conversations and consultation are important where the cultureis able to challenge priorities without fear of retribution.

To deliver the new operating framework; moving into the thirdstage of reform, using “additional capacity and the reform leversto transform services and deliver high quality care for patientsand value for money for the tax payer” (David Nicholson,2009/10 Operating Framework) emphasises making quality theorganising principle, spanning three areas, “safety, effectivenessand patient experience” (see above) and relying on managers toenable the changes necessary to deliver.

Effective people management is about vibrancy, energy,direction and celebration.

It’s also about managers and leaders being coherent andconsistent. If you are a leader in Health and/or Social care, then

it is important to be open and explicit about what you stand forand what drives you within a moral framework. In today’schanging landscape common sense intelligence must prevail,looking for improvements across services, not only in yourorganisation is vital. Recognising the importance of emotionalintelligence when dealing with issues and people and developinga physical intelligence - intelligence about your own physicalneeds - enables a resilience that will enable you and your teamto cope well with changes in both your personal and workcircumstances

If what you are being asked to do and are asking others to dodoesn’t make sense - confusion will lead to frustration. There hasto be clarity for everyone, which may mean challenging prioritiesto gain consensus.

Evidence that you are preparing for the future, that you areengaged with your staff, the public and patients/clients/citizensand that you are involving staff in the design and delivery ofclinically led services is demanding but indispensable. At all timesyour purpose and values need to be transparent and your clearvision will link to your values and help staff to know where theyfit in. Your staff will know that they matter and will understandthe contribution they make in delivering an agreed vision in anever-changing environment.

Change within Health and Social care is not an option, butwith change comes an emotional response and people respondindividually to that change. Some will embrace change, otherswill find it more difficult and a typical change process will mirrorthe grieving process; finding oneself in denial - refusing to acceptthat change is happening, leading to anger and individuals tryingto bargain a position for themselves. Unfortunately this maysometimes lead to depression, but ultimately there is often (butnot always) an acceptance of change.

Managing your own and others’ emotions associated withchange is vital to enhance both individual and organisationalperformance, knowing how to support individuals, knowing thateach person will have their own interpretation of the change andproviding opportunities where the change can be discussed,individuals can be updated, and involving staff in the actualchange will help to achieve positive results.

Effective people management is made easier if common goalsare set and understood, if there is a culture of developing theteam as well as individuals’ capacity and capability, so that people


The NHS management style hasbeen notorious for its ‘commandand control’

Set common goals, develop theteam, make people feel valued

Integrated Care

are made to feel valued and are developing within theorganisation. Being both supportive and enabling as well aschallenging in a constructive way will command respect, and thiswill develop further if you as a leader are prepared to bechallenged, thus stimulating trust and respect.

Valuing people is written into every stage of peoplemanagement, through leadership, the use of policy and strategyto support clear goals and being empowered to act on ideas,offering relevant and sufficient resources and having clearprocesses that will lead to people satisfaction, patient / clientsatisfaction and will deliver a quality service that will havebusiness results as well as developing a positive and energeticteam.

There have been many debates about the principles thatunderpin effective people management. As a leader it isimperative that you have a clear understanding of theenvironment in which the organisation operates, this will enableyou to align your business objectives to desired outcomes andgive the people you manage clarity of purpose.

You have a responsibility to recruit people who will alsosupport the organisation’s mission and strategy through theircompetence, energy and passion and then manage them well bybeing steady and consistent in the messages you give them andactions you ask of them. You need to make sure there is a goodfit between the skills people have and the jobs they do.

Sometimes working in a changing culture demands a changeof behaviour, both from yourself and the people you manage.You can work on this together identifying the changes that areneeded, agreeing them and putting a programme in place tosupport these changes.

It is so important that you let patients / clients / citizens, driveyour culture and therefore your structure. This will make sense toyour employees. If you implement the right systems to supportpeople in their work, you will create a climate of alignment andsuccess.

A good team is self sustaining and supportive, so nurturing theteam is vital, building bridges between people, challenging, butalso celebrating and humour add to the sustaining quality ofteams. You need to give, within reason, employees what theyneed to succeed and in some cases this will mean that you willhave to get out of the way!

Beware of false indicators of success. Recognising a broadbalanced approach is the only way successfully to sustain

organisational performance and that a productive employee is ahappy employee.

Too often we hear of poor management; unclear vision, a lackof resources and ‘ultimatum management’. Too often this leadsto low morale, underperformance, high sickness rates, high staffturn over and poor services for patients.

Effective people management is not rocket science, but it doesrequire a genuine interest in the way people function and thriveso that conditions can be created where individuals have afulfilling and satisfying work life which contributes to a successfulorganisation. Health and Social Care managers have successfullymanaged change over a long period of time, there will be moreto come, so don’t fight it embrace it. ■

BIOGRAPHYSusan Hodgetts was appointed as Chief Executive of theInstitute of Healthcare Management and took up post on4th July 2006. Since 1 January 2008, Sue has also beenacting as interim CEO for the national Centre forInvolvement. Sue has extensive experience in the field ofeducation and training both within and external to theNHS.

Previously, Sue held high profile positions withineducation organisations and NHS education and trainingbodies including five years as Chief Executive of the Devonand Cornwall NHS Workforce Development Confederation,where she built the organisation from its inception.

Sue has a passion for developing organisations in orderto maximise the potential of both their staff and theirresources. Sue’s hobbies include mountaineering, sailing,theatre and film and enjoying her leisure time with familyand friends.


Let patients, clients, citizens driveyour culture and your structure

Integrated Care


Funding Modelsfor Integrated CareOrganisationsDr Rebecca Rosen

In its most complete form, integration is a single system of needsassessment, commissioning and /or service provision aiming topromote alignment and collaboration between cure and care

sectors. The primary goals of integration are to enhance quality ofcare and quality of life for patients while making more efficient useof resources1.

There is no set ‘form’ for integrated services and organisations.The structures and processes through which teams andorganisations work more closely together - ie achieve closerintegration - will vary according to local context including history,relationships, funding arrangements and politics. Integration maybe ‘real’ - achieved through formal organisational mergers - or‘virtual’ where a network of teams and organisations workcollaboratively towards common goals.

Many factors will support and drive integration - includingprofessional commitment, patient demand and health care policy.However the extent to which financial flows and paymentmechanism are aligned to support and incentivise collaborationbetween providers is a key determinant of success. Recent NHSpolicy on choice, competition and payment by results has drivenchange and improvement in elective care, but done little toencourage collaboration between services aimed at people withcomplex, long term conditions..2

Financial models through which to achieve greater integrationbetween services will vary according to goals to be achieved, theorganisations involved and the political and organisational contextin which they are operating. They range from small scale targetedpayments to reward specific behaviours through to ‘whole system’funding to align incentives across all organisations in an integratedservice. Four key financial models can be identified - although theyare not mutually exclusive and may be used in combination: • Micro-incentives • Pooled budgets • Integrated budgets • Integrated delivery systems with a unified budget

MICRO-INCENTIVESMicro-incentives typically take the form of payments for specific

desired activities or behaviours. The Quality and OutcomesFramework for general practice exemplifies this kind of targetedincentive - linked to pre-specified (mainly evidence-based) standardsthat must be achieved in order to qualify for the payment.

Taken one step further, targeted payments can be used toincentivise clinicians (whether GPs or other professionals) to act inaccordance with integrated care pathways that span primary,community and/or hospital care. Aims may vary, but includeincentivising GPs to carry out activities that can be done in primary

care (eg spirometry) freeing up capacity in hospitals (throughadmission avoidance or early discharge schemes) and encouragingpractice in line with agreed care pathways.

An example of the latter is seen in East Lincolnshire’s COPDservice which used Local Enhance Service (LES) payments toincentivise GPs to:3

• Develop systematic screening and identification of patients withCOPD

• Optimise treatment in line with guidelines • Refer appropriately to specialist services Pick up from specialists

to support earlier hospital discharge

Once these basic elements of primary care COPD managementwere established a second LES was introduced to incentivise moresophisticated engagement between primary and communityclinicians and hospital specialists.3

• Provide and acute assessment and home management services• Provide an early discharge scheme in the community• Offer community review 4 - 6 weeks after an acute COPD episode• Assess and manage patients with complex needs

A local evaluation reported that over 200 acutely ill patients wereassessed and managed in the community, implying significantdiversion of patients away from hospital care. Although theseinitiatives did not result in the formation of a single discrete unifiedorganisation of which all clinicians were ‘members’ it stimulatedelements of virtual integration between hospital specialists, specialistteams and community based clinicians. The incentives promoted aco-ordinated approach to COPD care that is consistent with thegoals of integration.

POOLED BUDGETS A second funding model that can align professional practice and

support integration is pooled budgets. Here, the teams ororganisations involved in providing a service identify that part oftheir budget that is spent on the disease or care group to whichintegrated care is targeted. The money is ‘pooled’ into a single fundfor integrated care, provided by ‘virtually integrated’ teams ororganisations (ie the teams do not merge but may act as if they werea single organisation with shared objectives, joint staffingappointments etc).

This approach was established through Section 31 of the 1999Health Act (now revised in S 75 of the 2006 Health Act) and can conferbenefits where common aims are pursued by multiple teams orservices for the same client group. They have been used for some timein services that bridge health and social care such as drug and alcoholservices and learning difficulties teams (see for example Salford PCT4)

Integrated Care

If implemented well, pooled budgets can result in thedevelopment of shared values, shared standards of care andcommon assessment processes. They can align practice across teamsand organisation to create a seamless service for patients. But thereare potential problems too, with a need for clarity about how thebudget will be managed and allocated; how to develop monitoringand reporting that is acceptable to all contributors and how tomanage variance in out-turn.

Guidance has been developed to address these issues5, but theeffectiveness of pooled budgets at supporting integration ultimatelydepends on the degree of trust and shared goals and values thatexist between participants, Budgets for integrated services ororganisations that have not invested in OD to develop shared goalsand build trust will not necessarily result in collaborative, effectiveand efficient working relationships.6

BUDGETS FOR INTEGRATED COMMISSIONINGA third financial model is seen where a single budget is created by

a PCT to procure a service for a specific care-group or condition thatcombines primary, community and/or acute sector care. This differsfrom the previous model because the commissioning PCT willdevelop a contractual relationship with a single organisation thatwill be held accountable for delivery of the contractual commitmentsof all participating teams and organisations.

This type of financial model is starting to emerge, with examplesseen in Sexual Health Services in Suffolk7 and a proposal by MiltonKeynes PCT to develop integrated commissioning for COPD that willspan primary, community and acute services.8 Commissioners facemany challenges in developing this approach. Not least are:specifying their service requirements in sufficient detail; Specifyingoutputs and outcomes to be achieved; setting quality standards;building constructive and open relationships with and betweenproviders; and performance managing such contracts.

If these challenges can be addressed, then integrated budgetscould incentivise the contract holder to ensure that participatingteams and organisation work efficiently and effectively together. Thismay either be through management of sub-contracts or through again sharing agreement that passes the financial incentives ofsavings onto other participants.

INTEGRATED DELIVERY SYSTEMSThe fourth financial model to support integration brings

together payment for and provision of health care into a single‘integrated delivery system’ (IDS). This arrangement is seen inselected health maintenance organisations (HMOs - although notall HMOs have a provider arm) of which the best known is perhapsKaiser Permanente in the United States. In this model, an annual‘capitated sum’ is allocated for each individual enrolled into theIDS, to cover all their care. The financial incentives between payerand provider and between hospital and community services arealigned, with the whole organisation aiming to reduce the overallcost of health care use by individual members. This encouragespromoting good health and preventing serious illness that willconsume resources.

The possibility of developing integrated payer-provider systems inthe NHS was raised in the recent Integrated Care Pilot ProgrammeProspectus9. To date, no such organisations have been established,although in some ways the short-lived ‘total purchasing pilots’ ofthe mid-1990’s were IDS’s.10 Practice based commissioning groupscould form the nucleus of similar organisations now if they are

allocated a global sum for all primary, community and acute sectorhealth and care services.

If they are to provide high-quality, cost effective care, IDSs will haveto address several challenges. They will need to manage financial riskand negotiate capitated budgets that reflect the health (and care)needs of their registered population. Recent work on person basedrisk adjustment11 will support budget setting that reflects the socio-demographic and morbidity characteristics of the population.However, smaller IDSs may need to carve out coverage of high cost,low-volume conditions that can destabilise financial planning. IDSswill need to develop data and information systems that supportneeds assessment, effective clinical practice and proactive targetingof care towards high risk individuals. They will need to developgovernance arrangements that manage conflicts of interest betweenprovider and commissioner roles, manage risk and maintainstandards. And they are likely to have to overcome political andpublic resistance to an incentive model that encourages primary caregatekeepers to reduce use of specialist and hospital services.

CONCLUSIONSWithout strong evidence to support a single ‘best’ model of

integrated care, the most appropriate funding model for any specificinitiative will depend on its objectives, scale, context andprovenance. That said, none of the above models are mutuallyexclusive. Integrated delivery systems make use of micro-incentives.Likewise, the teams and organisations that come together to deliverservices under an integrated budget offered by a PCT may well usemicro-incentives and/or pooled budgets to align objectives anddeliver change. However, novel funding models will not deliverintegration on their own. They must be accompanied by rigorousorganisational and professional development to ensure that theindividuals and organisations involved are enabled to deliverintegrated care that the financial models aim to incentivise. ■

REFERENCES1 Rosen R and Ham C. Integrated Care Lessons from Evidence and Experience.

London, Nuffield Trust, 2008.2 See for example Ham C. Clinically Integrted Systems. The next step in English heatlh

reform? London, Nuffield Trust, 20083 Details of this initiative can be found at http://www.bmc.n-i.nhs.

uk/docs/East%20Lincolnshire%20COPD%20Programme.pdf Accessed 19/1/20094 http://services.salford.gov.uk/solar_documents/BASC06090610.PPT (accessed Jan

21st 2009)5 Home Office, Dept of Health and Dept for Education and Skills (2002) for example.

Young Person’s Substance Misuse Schemes - pooled budgets. Prospectus for PilotSchemes.: http://drugs.homeoffice.gov.uk/publication-search/young-people/substance-misuse-service?view=Binary Accessed 21st Jan 2009

6 Hultberg E, Glendinning C, Allebeck P and Lönnroth K. 2005 Using pooledbudgets to integrate health and welfare services: a comparison of experiments inEngland and Sweden Health & Social Care in the Community Vol 13 (6) 531 - 541

7 Details available at http://www.suffolkpct.nhs.uk/Consultations/FormalConsultationonSexualHealthServices/tabid/694/Default.asp (Accessed Jan 19th2009)

8 Gray, D. Public Health Consultant Milton Keynes PCT. Personal Communication.9 Dept of Health. Integrated Care Pilots: prospectus for potential applicants. London;

HMSO, 200810 Goodwin N, Mays N, McLeod H, Malbon G, Raftery J. 1998 Evaluation of total

purchasing pilots in England and Scotland and implications for primary care groupsin England: personal interviews and analysis of routine data. BMJ. 1998 July 25;317(7153): 256-259.

11 For further detail, see http://www.nuffieldtrust.org.uk/projects/index.aspx?id=338 (accessed Jan 19th 2009)

CONTACT INFORMATIONDr Rebecca Rosen, Senior Fellow, Nuffield Trust, LondonEmail: [email protected]


Integrated Care

Long Term Conditions 19

Developing Primary andCommunity Care BasedPersonalised Care Plans withPeople with Long Term ConditionsDr David Colin-Thomé. National Clinical Director for Primary Care.Directorate of Commissioning and Systems Management, Department of HealthDr Alf Collins. National Clinical Lead of the Health Foundation’sCo-creating Health InitiativeDr Simon Eaton. Clinical Lead for Long Term Conditions, NHS North EastTracy Morton. Long Term Conditions Team. Directorate of Commissioning andSystems Management, Department of HealthDr Sue Roberts. Chair Programme Board Year of Care Programme and Former NationalClinical Director for DiabetesPOLICY BACKGROUND

The major thrust of government policy in recent years has beento offer personalised care to service users whether they arepatients of the NHS or clients of social care. Care planning, whoseorigins are primarily in social care but are an important feature ofmental health services for those with more severe forms of men-tal illness, offers an excellent opportunity to personalise care forthose primarily with long term conditions (LTCs). Care plans willonly be successful as an enabler if they are couched in bio/psycho/social terms depending on service users’ wishes or needs,and care planning takes on a participatory form by facilitating theconcept of the ‘meeting of two experts’- the patient and theirclinical carer. Hence our commitment in this article to the basictheme ‘it is primarily a verb not a noun’. Planning is the focus, theplan being the record of that process.

The original policy commitment on care planning came inthe Our Health Our Care Our Say1 white paper of 2006 whoseoverarching ambition was to shift influence and power to theindividual and the public;

“By 2008 everyone with both long term health and socialcare needs will have an integrated plan if they want one andby 2010 everyone with a LTC will be offered a care plan”.

This was repeated - with a slightly different form of words in thePrimary and Community Care Strategy2 of the NHS Next StageReview of 2008;

“Everyone with a long term condition will be offereda personalised care plan that is centred around them andtailored to their individual needs”.

But the policy had been developing apace. The NHS Improve-ment Plan3, building on the NHS Plan (2000)4 to re-engineer the

NHS around patient pathways, was published in June 2004 and setout the next stage of the Government’s plans for the modernisa-tion of the health service by putting patients and service users firstthrough more personalised care.

Choice for service users is an important component of person-alisation and is often drawn too narrowly. Choice embraces threekey components designed to improve people’s overall experienceby providing them with more:

Power to shape their pathway through services and keep controlover their lives

Preferences to choose how, when, where and what treatmentsthey receive

Personalised services organised around their lifestyles.

Care plans are also an important vehicle and enabler for the DHprogramme of world class commissioning. Care plans facilitate‘micro’ commissioning for the individual patient/client butcomponents of the care plans that can be aggregated identify theneeds of their patients/clients that ‘meso’ organisations (PBC fortheir populations) or ‘macro’ organisations(PCTs/LA) can utilise asthey commission services for their populations. So care planning hasto be personal for the individual yet ideally, the plan itself should bea basic template to enable aggregated needs to beidentified. This is described in more detail in recent guidance to theNHS and social care Commissioning Personalised CarePlanning: A guide for commissioners5 and will be further re-iteratedin guidance for the NHS workforce to be published in early 2009.

Individual budgets, whether those already available for socialcare users and in the piloting of health care personal budgets, areanother and potentially most significant shift in putting serviceusers in control of their futures. The care planning process will bean essential enabler here; ensuring people with long term condi-tions can identify their individual needs which they can then use to

Integrated Care

inform and develop their personal budgets. The electronic recordwill become the repository of personal information for the indi-vidual service user in updating and in transmitting their plans totheir clinical carers.

Quality of care is defined in the Next Stage Review as ensuringpatient safety, effectiveness of care and the patient’s experience ofthat care. Care planning with a trusted professional and a planthat is a manifestation of that participatory process can only butensure quality. The meeting of two experts is enhanced if there isa resultant ‘compact’ between them.

The increased emphasis on personalisation, delivered throughcare planning, signals the government’s desire to move thisagenda further forward. This can only happen if there is systemsand culture change aligned with the wider personalisation agendaand health reform - especially commissioning. We need to developthe right leadership and “champions” on the ground. There needsto be improved collaboration and partnership between health,social care and the third sector (including shared outcomes andmeasures of success) and crucially, a change in approaches andbehaviours of the workforce with a move away from paternalisti-cally “doing to” people to developing a relationship of equal part-nership that allows shared decision making- ‘doing with’ people.

PRACTICAL IMPLEMENTATIONInternational evidence6 tells us that best outcomes are achieved

when there are a) systematic proactive services, b) people engagedin their own care and c) healthcare professionals and people withLTCs working in partnership. The Diabetes Year of Care programmeand the Co-Creating Health initiative are two national service trans-formation programmes that are informed by this philosophy.

The Year of Care programme has produced the house model7 tohelp organisations to transform services by understanding thevarious elements that need to be in place to enable care planning towork in everyday practice. At the centre of the model is theconsultation process itself, surrounded by all the importantcomponents. The house metaphor emphasises the importance andinter-dependence of each element - if one is weak or missing thestructure is not fit for purpose. It acknowledges the role ofcommissioning as the foundation upon which to build all of the work.

The Co-creating Health model is similar, but places greater em-phasis on consultation skills training for clinicians.

Engaged, activated and informed PatientsTo support and enable people to self care optimally, they need

a good understanding of their condition and an understanding oftheir role in working in partnership with their HCP. The concept ofactivation8 describes the degree to which people feel confident toself care. The model would suggest that commissioners shouldbe interested in supporting this via a range of interventions. Thesemight include written explanatory material about care planningitself, and patient education and support groups as part ofroutine care.

One specific intervention that has been shown to be helpful isensuring that people with LTCs are prompted to prepare for theirclinic appointments. The form of the prompt could be a ‘choicemenu’, where people are invited to choose items to discuss inclinic. Other strategies include ensuring people with diabetes knowtheir blood results well in advance of the appointment, so thatthey have time to think about the relevance and importance tothem. This can transform the care planning consultation positivelyfor both the patient and the healthcare professional9. It is the roleof the HCP to (at least) ensure that they do not reduce the level ofactivation and (at best) support people in developing confidenceto self care.

Healthcare Professionals committed topartnership working

Supporting people who live with LTCs requires clinicians to adopta different role to that of the traditional ‘diagnoser and treater’.By definition, LTCs are incurable and the effects are permanent andvariable. People who have LTCs cannot expect full recovery and needto acknowledge, understand, incorporate, accommodate andadapt to their condition before they can truly ‘move on’. It is theclinician’s role to support people to be able to achieve these things.

The health care professionals (HCPs) are the ‘experts’ in the un-derstanding of disease. However, the person with the LTC willknow best how proposed treatments or support mechanisms fitinto their lives, and what will work for them in their situation.While they may value help to work this out, they need to be thefinal decision makers in order to put their plans into action.

Long Term Conditions

Organisationalprocesses

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Integrated Care

A clinician committed to such partnership working is essentialfor care planning to be successful, but while most cliniciansbelieve they are working in this way, only half of patients reportthat is the case10. Both the Co-creating Health Initiative and theYear of Care programme offer professional developmentprogrammes to support clinicians to feel confident in working inoften very new styles of practice. So practitioners wanting to getinvolved in care planning will not only need to reflect on their newrole, they may need to take part in further training. Commission-ers will need to make this available.

One of the difficulties facing HCPs wanting to change theirconsultation styles is the lack of effective feedback or ability tomeasure change. However, questionnaires are now available whichmay be able to distinguish the subtleties of consultation qualityand partnership working and assist individuals or organisations inmeasuring quality improvements11. Measures of the patients’perception of the process of care planning need to becomecommonplace among the various metrics in clinical practice.

The organisation in practice No amount of good intentions will change practitioner

behaviour if the working environment is not supportive. If thetiming of appointments is wrong, if patients don’t have theinformation or understanding to take part, if the workingpractices are geared to tick boxes and if the commissioner ismeasuring the number of care plans rather than involvement inthe new process of care planning, things are unlikely to change.Indeed recognising that it is the verb ‘care planning’ rather thanthe noun, or piece of paper ‘care plan’ that is important is one ofthe most important aspects of the new guidance from theDepartment of Health for commissioners.

The organisation at practice level is critical. The ‘tiles’ on the roofinclude the foundation of systematic care, disease registers to aidrecall, but also the clinic experience and other aspects of accessand communication. Making sure that patients have the right toolsto stimulate their thinking or the right test results beforehandrequires some practice reorganisation. IT systems can eithersupport health care professionals to do the right thing, orreinforce old ways of working.

The Year of Care project has helped to develop templates thatsupport partnership working and record those things which areimportant to patients, and professionals as well as commissioners,enabling them to identify the support services they need toprocure. These templates, designed for GPs systems are now undertest within Yorkshire and Humber Strategic Health Authority andcommissioners will need to understand and support the introduc-tion of these tools in future..

Overall, clinicians and services need to work well together.Most people with LTC are independent, but many may have com-plex health and social care needs. Personalised care planning

needs to understand the specific needs of each individual andensure effective coordination of health and social services toaddress these.

Finally, the system should be aligned such that the care plan-ning conversation is facilitated. Then, the process of care planningand the care plan itself can feed back into the system to ensurethat commissioning, care co-ordination and integration of servicesare truly arranged around the wishes and needs of patients. ■

REFERENCES1 Our health, our care, our say: a new direction for community

services. Department of Health. 20062 NHS Next Stage Review: Our vision for primary and community

care. Department of Health 20083 The NHS Improvement Plan: Putting people at the heart of

public services. Department of Health 20044 The NHS Plan: a plan for investment, a plan for reform. De-

partment of Health 20005 Supporting people with long term conditions: commissioning

personalised care planning - a guide for commissioners. De-partment of Health. 2009

6 Wagner EH, Austin B, Von Korff M: Improving outcomes inchronic illness. Manag Care Q 4:12-25, 1996

7 Eaton S, Walker R. Partners in Care: A Practical Guide toImplementing Care Planning. 2008 http://www.diabetes.nhs.uk/news-1/Partners%20in%20Care.pdf/view

8 Hibbard J, Stockard J, Mahoney E, Tusler M. Development ofthe Patient Activation Measure. Health Serv Res 2004Aug;39(4.1):1005-26

9 Ludbrook S, Doherty Y, Lewis-Barned N. What do patients andclinicians think of the Year of Care? (Abstract) in press: Diabeticmedicine 2009

10 The 2008 Commonwealth Fund International Health Policy Sur-vey of Sicker Adults. http://www.commonwealthfund.org/Con-tent/Surveys/2008/The-2008-Commonwealth-Fund-International-Health-Policy-Survey-of-Sicker-Adults.aspx

11 Mercer S, Howie J. CQI-2 - a new measure of holistic interper-sonal care in primary care consultations. BJGP 2006;56(525):262-268


Integrated Care

Long Term Conditions22

Improved Access toPsychological Therapiesand Integrated CareDr Alan Cohen, GP and James Seward, Director of the IAPT programme

Improving Access to Psychological Therapies (IAPT) is aDepartment of Health programme which will help the NHSoffer NICE-compliant psychological therapies for treating

common mental health problems. People who have a physicallong term condition (LTC) and those whose employment is at riskfrequently have an underlying mental health problem likely toinfluence their outcome adversely. IAPT has examined these twogroups within its broader health priorities. Here we describe thebackground and characteristics of the programme and how carecan be integrated to provide the best possible outcomes for ourclients and patients.

BACKGROUND TO IAPTIn December 2004, Lord Layard, Emeritus Professor of

Economics at the London School of Economics, attended aDowning Street seminar on worklessness. He quoted statisticsthat showed that 40% of those people on long term IncapacityBenefit suffered from a common mental health problem, forwhich NICE (National Institute for Clinical Excellence) guidelinesindicated there was appropriate therapy. He proposed thatinvesting in training and recruiting more professionals to deliverpsychological therapies for those people who were on IncapacityBenefit, would improve their chances of returning to work; thatthere was an economic argument, as well as a health and well-being argument to support this proposal. The Labour Partymanifesto in 2005 committed to progressing this, and later thatyear invested significant new funds in two demonstration sites(Newham and Doncaster). These two sites, supported by anational group of experts over the next eighteen months,developed their clinical services, as well as providing evidence tothe 2007 Comprehensive Spending Review(CSR), on theoutcomes that these services were able to provide. Based on thisevidence, the Secretary of State for Health on World MentalHealth Day, 10 October 2007 announced new funding for anational programme to begin the roll out of improved access topsychological therapies across England.

The Secretary of State committed new funds rising to £173mby 2010/11 to recruit and train 3,600 new therapists, who wouldtreat 900,000 people, of whom half who complete treatment(according to the best evidence) could be expected to achievemeasurable recovery.

CHARACTERISTICS OF THE IAPT PROGRAMMEThe IAPT programme is a commissioner led, outcome focused

programme, delivering NICE compliant therapies, for people with

common mental health conditions.The programme is commissioned by the local PCT either

directly or by encouraging practice based commissioning toshape the development of the service. The national programmeteam has produced information for commissioners based in PCTsand practices to support their work, available atwww.nhs.uk/iapt . Commissioners decide the most appropriateprovider of their local service. In some of the first wave sites,voluntary sector providers have secured the contract but in mostthere is a partnership of statutory and voluntary providersworking in an integrated fashion to deliver a comprehensiveservice in primary care settings in local communities.

The national experts, working with the two demonstrationsites, developed a set of clinical outcomes covering four domainsof quality against which the service is commissioned. This hasbecome a nationally agreed minimum data set. A characteristicof this data set is that a defined outcome measure needs to beperformed at every clinical contact the patient/client has with theservice. Since the data being gathered is the same in each IAPTsite, it is possible to compare clinical outcomes within a site, andbetween sites. This offers an unrivalled opportunity tocommission against Patient Reported Outcome Measures(PROMs).

While the exact delivery model will depend on localcircumstances, there is a requirement that a stepped careapproach is delivered, in line with NICE. The stepped careapproach is reflected in the workforce, with therapists deliveringeither high intensity therapy or a low intensity intervention. Alow intensity intervention is characterized by approximately fivecontacts with the patient/client, which may be face to face or useother methods such as the telephone. Low intensity interventionsare appropriate for people with, for example, mild to moderatedepression, or early stages of panic or generalised anxietydisorder. Low intensity interventions include guided self help,exercise therapy, bibliotherapy, and computerised cognitivebehavioural therapy.

High intensity interventions are characterized by at least 12

A stepped care approach isdelivered, in line with NIC

Integrated Care

face to face consultations, and are appropriate for people, forexample, with moderate to severe depression, obsessivecompulsive disorder, or post traumatic stress disorder. Highintensity interventions include cognitive behaviour therapy, andinterpersonal therapy.

The skills required by the two sets of staff - therapists andtherapy workers - are different, and extensive work has beendone to describe the skills and training needs for these groups ofworkers. More information is available at www.nhs.uk/iapt .

Care is provided by a multi-disciplinary team, including highand low intensity therapists, clinical supervisors, administrativesupport, employment support workers, and a GP lead/champion.The role of the GP clinical champion is two-fold: to link bothinternally with the new IAPT service so that the team understandshow primary care works, and advise on the relationship betweenlong term conditions, and common mental health problems. Theexternal role is to ensure that primary care services understandwhat the IAPT service can provide, how to refer patientsappropriately, and to understand the link between practice basedcommissioning and the new IAPT services.

LONG TERM CONDITIONS (LTC)There is extensive evidence for the link between some long

term conditions and common mental health problems. The bestreview is the 2005 Formal Investigation undertaken by theDisability Rights Commission.

Diabetes: depression has a prevalence in the generalpopulation of between 3 - 5%, while in people with diabetes itcan be as high as 15%. The presence of depression in people whohave diabetes increases self perceived symptom load - they feelmore unwell, are more likely to use hospital and primary careservices, and are more likely to use more medication than peoplewith diabetes who are not depressed. However, there isconflicting evidence as to whether or not the glycaemic controlof a depressed diabetic improves if the depression is treated.Evidence from the US indicates that the extra costs of diabeticcare for people with depression is increased by between 70% and249%. It may not be appropriate to apply exactly the sameincrease in costs to health care in the UK, but without doubtcosts are increased.

Ischaemic Heart Disease: People with ischaemic heart diseaseare two to three times more likely to suffer from depression than

those without. The presence of depression is the best indicatorfor death following a heart attack. 25% of those presenting to anacute chest pain clinic suffer from no cardiac abnormality, butdo have panic disorder.

Chronic Obstructive Pulmonary Disease (COPD): Up to twothirds of people with moderate or severe COPD also suffer frompanic and anxiety disorders. A common scenario is thatsomebody with severe COPD fears that they are becoming moreshort of breath, calls an ambulance, is admitted as an emergency,remains in hospital for a couple of days, and then is discharged.The cost to the health service is significant, and the underlyingproblem, a fear of becoming short of breath, rather than anactual exacerbation, is not addressed.

MEDICALLY UNEXPLAINED SYMPTOMS (MUS)This term is used to describe those people who have physical

symptoms, for example headache or abdominal pain, for whichthere is no underlying physical illness/abnormality that explainstheir symptoms. People with MUS constitute up to 20% of GPconsultations, and people severely disabled by MUS account for5% of GP consultations. Work in both the UK and the USindicates that up to 50% of people attending medical outpatientdepartments in acute hospitals have medically unexplainedsymptoms. These people go on to be investigated, referred toother colleagues, without ever addressing their underlyingmental health needs. A case of the wrong patient, being treatedby the wrong doctor, in the wrong hospital at the wrong timeand a waste of finite NHS resources.

WORKLESSNESS40% of people on incapacity benefit, have a mental health

problem - and some 95% of these suffer from common mentalhealth problems. Of the 1,000,000 who report sick each week,3,000 are still out of work 6 months later, and 2,400 are still sickafter 5 years. People off work for twelve months, are likely to beoff work for a further 6 years, and those off work due to ill healthfor 24 months, are more likely to retire, or die, than ever returnto work.

The unemployed have higher mortality rates, poorer generalhealth, poorer mental health, higher medical consultation rates,greater medication consumption, and increased hospitaladmission rates.


Extensive evidence links longterm conditions and commonmental health problems

40% of people on incapacitybenefit have a mental healthproblem

Integrated Care

Given the above statistics, it is not surprising that addressingthe mental health needs of those whose employment is at riskbecause of a common mental health problem is a priority. Byensuring that the IAPT multi-disciplinary team includesemployment support advisors, the overlap between worklessnessand common mental health problems is addressed in acoordinated and planned fashion within a single team.

The Department of Work and Pensions (DWP) have committed£4m to pilot the role of employment support workers in IAPTteams to help people stay in work when their mental healthproblems put them at risk of losing their job.

INTEGRATED WORKING AND GOVERNMENT PRIORITIESThe IAPT programme is not simply about managing people’s

depression and anxiety. People rarely fall neatly into onediagnostic category. People with depression may also havetrouble with their work or have poorer control of their diabetes,or their angina may not respond well to medication. This overlapand blurring, is characteristic of the complexity of modern lives.What is more, people want to be treated as a single person, notas a number of disorders that need to be managed by differentdisconnected groups of professionals. It is for this reason thatintegrated working is so necessary - to treat the individual as anindividual - with a number of needs, which must be addressedtogether, coherently, by a multi-disciplinary team.

This approach has been made a priority in healthcare by thework of the Minister for Health Lord Darzi in his recent NextStage Review of the NHS. He has recommended both the need tocommission services based on the outcomes of the treatment asperceived by the patient - Patient Reported Outcome Measures(PROMs) - and for the need for health care to be coordinated,person centred, and local. The best example is his proposal forlocal health centres, that would be resource centres for hospitalinvestigations, scanners and so on, as well as medical clinics andthe base for local social care services. One can imagine a HealthCentre with an MRI scanner, next door to a psychologicalassessment centre - when people with a headache need furtherinvestigation, they can have both a physical assessment (the MRIscanner), and a psychological assessment (IAPT) at the same time.

Reducing worklessness and encouraging people to return towork, has been a Government priority for some years. DameCarol Black was asked by the Prime Minister to prepare a report

on Work and Well-being, which was published in 2007. TheDepartment of Health’s response to that report was published in2008, and endorsed many of her recommendations. Theseincluded the need for psychological support for those whoseemployment was at risk because of a mental health problem, andthe need to link effectively between employment services, andmental health care.

CONCLUSIONIt is clear that IAPT services need to be part of a wider

programme of integrated care involving different types of healthcare provider, as well as social care and voluntary and statutorycare providers. IAPT offers people with common mental healthproblems, a nationally consistent, evidence-based, high qualityservice - the first time that such support has been available tothese patients. ■

REFERENCESWeb sites:www.iapt.nhs.uk

outcomes toolkit:http://www.iapt.nhs.uk/2008/07/improving-access-to-psychological-therapies-iapt-outcomes-toolkit/

workforce and curricula:http://www.iapt.nhs.uk/services/workforce/

NICE Depression guideline:http://www.nice.org.uk/Guidance/CG23

NICE Anxiety Guideline:http://www.nice.org.uk/Guidance/CG22

Disability Rights Commission Formal Investigation:http://www.equalityhumanrights.com/en/publicationsandresources/Pages/DRCHealthFIClosingthegapmainreportpart2.aspx?k=Closing%20the%20Gap

Medically Unexplained Symptoms:http://www.iapt.nhs.uk/special-interests/medically-unexplained-symptoms/

Mental health and worklessness:http://www.scmh.org.uk/publications/work_and_wellbeing.aspx?ID=533

BooksDelivering Mental Health In Primary Care; an evidencedbased approach. RCGP 2008 ed A.Cohen chapter 2.

Long Term Conditions24

Employment services and mentalhealth care need to be effectivelylinked

Integrated Care

Respiratory Care 25

The Need for an IntegratedApproach to the Care of ChronicObstructive Pulmonary DiseaseRA Stockley, Professor of Medicine, Birmingham andR Stepney, Medical Writer, Charlbury Oxfordshire

Close to a million people in the United Kingdom have beendiagnosed as having chronic obstructive pulmonarydisease (COPD), and a further two million are thought to

be affected by the condition but undiagnosed1. COPD is a majorcause of mortality: in 2004, more than 27,000 people died fromthe disease2. It is also associated with significant morbidity asincreasing breathlessness on exertion restricts opportunities foremployment, limits activities of daily life, increases dependencyand enhances isolation1. The social class gradient for respiratorydisease in general is steeper than that for ischaemic heart disease,and this is particularly evident for COPD: men aged 20-64 whoare unskilled manual workers are 14 times more likely to die fromthe condition than men engaged in the professions2. COPD iscaused predominantly by smoking and occurs disproportionatelyin economically disadvantaged communities which may makerelatively little use of opportunities for screening and diseaseprevention1.

Our approach to the condition therefore requires a focus farbroader than purely medical. However, that aspect of care alonerequires considerable resources. In 2004-5, chronic obstructivelung disease accounted for 111,000 emergency admissions toNHS hospitals in England, 186,000 finished consultant episodes,and more than one million bed days2. The direct cost to theNational Health Service of caring for patients with COPD isestimated to be £500m1. More than half of this is accounted forby hospital services, but the burden on primary careis also substantial.Recently, the governmenthas emphasised theimportance of improvingstandards in themanagement of chronicconditions such as COPDand of designing servicesthat are tailored to theneeds of the individualpatient, that areintegrated, and that aredelivered as close to thepatient as is practical1.Commissioning ofservices by primary caretrusts (PCTs) is seen ascentral to this process.

The chronic course of COPD is punctuated by acuteexacerbations which are a major cause of reduced quality of lifeand associated with more rapid decline in lung function3. Ameta-analysis of randomised controlled trials showed thatmaintenance therapy with salmeterol results in a clinically andstatistically significant reduction in likelihood of moderate/severeexacerbations when compared with placebo or patients’ usualtherapy4. In patients with more severe COPD, adding an inhaledsteroid to a long-acting beta agonist further reducesexacerbation rate, presumably by suppressing the inflammatorycomponent of the disease5,6. Data indicate that long-actinganticholinergic agents also reduce exacerbations7. However, therecent Optimal study failed to show an additional benefit of allthree classes of drug on exacerbations8.

The majority of patients even on optimal medical therapycontinue to experience at least one exacerbation a year; andinterventions incorporating a range of non-pharmacologicalelements have also proved effective in improving outcomes.

A randomised trial in Norway showed that a programme ofeducation and self-management in patients with mild/moderateCOPD significantly reduced the number of GP consultations anddrug requirements over a year of follow-up9. Patient satisfactionwith treatment was improved, and the mean total cost of primarycare management of the condition was almost halved comparedwith the control group. A more recent randomised trial inLondon found that a care package incorporating pulmonary

rehabilitation, educationin self-management, apersonal action plan andhome visits significantlyreduced deaths fromCOPD over a twoyear period10. Hospitalreadmission rates werenot affected, but thenumber of unscheduledGP contacts fellcompared with thecontrol group.

An integratedmanagement initiativedeveloped in Doncaster,an area with a highprevalence of COPD, has

Integrated Care

reduced hospital admissions for acute exacerbations comparedwith historical controls (report in press). The project combinedtraining sessions for healthcare staff organised by the PCT withthe distribution of self-management materials to patients. Theseincluded advice on assessing and reporting shortness of breath,sputum volume and sputum purulence, as indicated by a five-point colour chart (Bronkotest). The colour chart had previouslybeen shown to identify exacerbations with a bacterial origin andhence direct antibiotic therapy and monitor resolution of theepisode11,12. There is evidence that antibiotic and steroid therapyare on average not initiated until 4-5 days after the onset ofsymptoms in purulent exacerbations13. It is logical to suggestthat earlier and more appropriate use of these agents mayreduce the severity of exacerbations and potentially healthcareutilisation and costs.

COPD is a condition in which patients repeatedly seek bothprimary and secondary care over a period of many years and inwhich social, environmental and behavioural factors have asubstantial influence on the course of the disease. It is in thiscontext that the National Clinical Strategy for chronic obstructivepulmonary disease in England is being developed14. This Strategy(formerly referred to as the National Service Framework forCOPD) is to be launched later this year [2009] and follows theidentification of this condition as “an increasing national burden”in the Chief Medical Officer’s Annual Report for 200515.

Sir Liam Donaldson’s Report called for more systematicdiagnosis of the condition, to be achieved at least in part by thetraining of primary care staff in spirometry, and improved qualityof care. The Healthcare Commission’s report of 2006 emphasisedthe importance of structured, proactive care even for patientsjudged to be at relatively low risk of hospital admission1. Itidentified the need for management strategies to span hospitaland primary care, to take the circumstances of the localcommunity into account, and for clinicians to consult patientson how services are experienced rather than delivered.

An Expert Reference Group has broadly endorsed thisapproach, while also commending innovative technology in thedelivery and monitoring of care. An example of one suchdevelopment might be the use of inflammatory markers toidentify patients most at risk of disease progression6. However, itis also clear that relatively simple methods of systematicallyassessing disease cause and severity — such as a scoring systembased on diary records of breathlessness, well-being and sputumcharacteristics — is useful in monitoring and communicating apatient’s condition and the effects of therapy13.

It can be expected that publication of the COPD Strategy willdraw both professional and public attention to the need for amore comprehensive and integrated approach to themanagement of a widespread and profoundly life-limitingcondition that has all too frequently been neglected. ■

REFERENCES 1 Clearing the air: a national study of chronic obstructive

pulmonary disease. Healthcare Commission, London, 2006.www.healthcarecommission.org.uk/_db/_documents/COPD_report.pdf; accessed 21.1.09

2 The Burden of Lung Disease 2nd edition: A statistics reportfrom the British Thoracic Society 2006, British Thoracic Society,London, UK

3 Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA.Relationship between exacerbation frequency and lungfunction decline in chronic obstructive pulmonary disease.Thorax 2002;57:847-852

4 Stockley RA, Whitehead PJ, Wiliams MK. Improved outcomesin patients with chronic obstructive pulmonary disease treatedwith salmeterol compared with placebo/usual therapy: resultsof a meta-analysis. Resp Dis 2006;7:147

5 Hanania NA. The impact of inhaled corticosteroid and long-acting beta-agonist combination therapy on outcomes inCOPD. Pulm Pharmacol Ther 2008;21:540-550

6 Parr DG, White AJ, Bayley DL et al. Inflammation in sputumrelates to progression of disease in subjects with COPD: aprospective descriptive study. Respir Res 2006;18:136

7 Freeman D, Lee A and Price D. Efficacy and safety of tiotropiumin COPD patients in primary care - the SPiRiva Usual CarE(SPRUCE) study.Respir Res 2007;8:45

8 Aaron SD et al. Ann Intern Med. 2007;146:545-555.9 Gallefoss F, Bakke PS. Cost-benefit and cost-effectiveness

analysis of self-management in patients with COPD - a 1-yearfollow-up randomized, controlled trial. Respir Med2002;96:424-431

10 Sridhar M, Taylor R, Dawson S et al. A nurse led intermediatecare package in patients who have been hospitalised with anacute exacerbation of chronic obstructive pulmonary disease.Thorax 2008;63:194-200

11 Stockley RA, O’Brien C, Pye A, et al. Relationship of sputumcolor to nature and outpatient management of acuteexacerbations of COPD. Chest 2000;117:1638-1645.

12 Woolhouse IS, Hill SL, Stockley RA. Symptom resolutionassessed using a patient directed diary card during treatmentof acute exacerbations of chronic bronchitis. Thorax2001;56:947-953

13 Vijayasaratha K, Stockley RA. Reported and unreportedexacerbations of COPD: Analysis by diary cards. Chest2008;133:34-41

14 Gruffydd-Jones K. A national strategy for the management ofchronic obstructive pulmonary disease (COPD) in England:aiming to improve the quality of care for patients. Prim CareResp J 2008:17(Suppl 1):S1-S8

15 On the state of the public health: Annual report of the ChiefMedical Officer 2005. Department of Health, London, 2006

Respiratory Care26

It canhelp you improve themanagementof patients with COPD by:

• Facilitating communicationbetween patients and health careworkers

• Helping guide definitive treatment,whether antibiotics or other formsof treatment, minimising the useof antibiotics to only those whoclinically need them

COPD exacerbations are the secondmost frequent cause of emergencyadmissions. We have developed aCOPD Cost Benefit Model that willallow you to explore the potentialimpact of this simple and inexpensiveintervention on COPD admissions.

Please contact us for further details.

BronkoTestSuite 4, Sovereign House,22 Gate Lane, Sutton Coldfield B73 5TT.Tel: 0845 226 3068. Fax: 0121 355 2420Email: [email protected]

BronkoTest sputum colour test

The BronkoTest sputum colour chartis part of a self management andaction tool for both HCPs and COPDpatients.

Integrated Care

Respiratory Care28

Caring For COPDPatients: The Role OfIntegrated CareDavid Price, Professor of Primary Care Respiratory Medicine, University of Aberdeen, andChairman of Research Committee of the International Primary Care Respiratory Group

An estimated 3 million people suffer from COPD in the UKbut only about 900,000 have been diagnosed and arereceiving treatment. Reports have highlighted that COPD

care is inconsistent and inadequate due to lack of awareness,incorrect diagnosis and a lack of clear care pathways. RhondaSiddall asks Professor David Price how the care of COPD suffererscan be improved and what role integrated care could play.

Q: WHAT ARE THE KEY CONCERNS IN RELATION TOTHE PROVISION OF CARE FOR COPD PATIENTS?

A: COPD places a significant burden on healthcare services.The estimated number of patients suffering from COPD equatesto about 1.4 million general practitioner consultations per year,up to four times the number of consultations for angina. COPDis the second largest cause of emergency admissions in the UK at130,000 per year and inpatient care for COPD accounts foralmost half the NHS expenditure on the disease. There is a lackof appropriate structured care, insufficient access to, andparticipation in, pulmonary rehabilitation, rising hospitaladmission rates and patients have a poor prognosis and poorquality of life. There is evidence that aspects of COPD care arenot adequately fulfilled in primary care, in spite of the Qualityand Outcomes Framework incentives and NICE guidance.

Q: SO WHAT NEEDS TO CHANGE?A: A lack of clear care pathways contribute to inconsistencies

in COPD care. The recommendations of the External ReferenceGroup that has advised on the development of the NationalClinical Strategy for COPD in England, due to be published inJune, suggest an integrated health service approach wouldensure consistent COPD care for patients at all levels of diseasefrom mild to severe. Integrated care models, overseen by amanaged clinical network, are the way forward.

Q: DOES ONE SIZE FIT ALL?A: In general, we know that we need to get better at the

diagnosis of COPD and reviewing patients. For the severe COPDpatient, an integrated health service approach may help reducehospitalisations due to exacerbations. For those with less severedisease, an integrated approach to care could improve quality oflife and for those with mild disease, an integrated approach tocare may help delay progression of disease. As with all chronicdiseases, we need a model where specialists work closely withGPs and you don’t have organisational or professionalseparation.

Q: SO WHAT WOULD A MORE INTEGRATED CAREAPPROACH MEAN FOR COPD PATIENTS?

A: Too often, patients, carers and family members experiencea system that is not very well integrated or co-ordinated. Weknow that COPD patients do not all have access to the full rangeof healthcare services that would benefit them and help toimprove outcomes. COPD care should be delivered by amultidisciplinary team working across primary and secondarycare as patients need access to physiotherapy, pulmonaryrehabilitation, nutrition advice, exercise advice, smoking cessationadvice and palliative care, as well as the clinical management oftheir symptoms. But the tricky question is: how best to ensurepatients receive all of this without having to work at getting it?No single model of integrated care will work for everywhere as itdepends on local circumstances.

Q: ANY SUGGESTIONS?A: One model of integrated care is for someone within primary

care, such as a GP with a special interest in respiratory disease ora specialist working in a secondary care clinic, to organise accessto this multidisciplinary team. In some places, this is happeningand is more the norm for patients with severe COPD. But for

David Price

Integrated Care

patients who are less severe who can be managed in thecommunity but still have complex needs and require access toother services such as smoking cessation clinics and pulmonaryrehabilitation, without an integrated model in place, they maynot get access to the full care package that could help improvetheir quality of life. The current issue for these patients in primarycare is that many are not reviewed regularly and when they are,the review may not be based on all the right questions and thisproblem may not be apparent if GP practices are working in silos.

Q: WHAT IS YOUR DEFINITION OF INTEGRATED CARE?A: My take on integrated care is that it is about the

systemisation of care. It requires leadership or at least someonetaking ownership of the commitment to ensure patients areprovided with full care packages, and it requires operationalprocesses. Integrated care is about delivering more and betterapproaches to care and health.

In simple terms, integrated care is about patients getting carethat is co-ordinated from the perspective of delivering bestpractice and based on aspiring for the best outcomes.

Q: WHAT SUPPORT COULD BE OFFERED TO PRIMARYCARE TEAMS TO FACILITATE INTEGRATED CARE FORCOPD PATIENTS?

A: There are a number of possible models and which are mostsuited to a particular GP practice, for example, varies on the sizeof the practice and whether or not the practice benefits from aGP with a special interest in respiratory disease and/or skillednurses in this field. One model is to provide training to practicesto enable a GP or nurse to provide an integrated care package forpatients. But there are many challenges to training beingeffective; the motivation of the practitioner is crucial and costsare always an issue. Another model is audit review services thatcould be provided by an outside agency skilled in COPDmanagement. Such an audit is based on “virtual” COPDassessments, which identify those patients whose disease appearsto be optimally managed with symptoms minimised and thosewho may require intervention from a number of differentservices. The audit is based on patient questionnaires andpractice data and results in a report sent by e-mail to the leadGP at the practice in question. The advice resulting from auditsare in line with best practice and NICE guidance. The idea is thatthe audit is the trigger for asking the question: is a particularpatient receiving optimum care.

Q: WHAT ABOUT OTHER MODELS OF INTEGRATEDCARE?

A: Another model is to move the epicentre of integrated careaway from the GP practice or an individual physician working insecondary care and set up a service to deliver integrated care.

The downside of this is that such a model disempowers individualdoctors, which I do not think is a positive trade-off. ■

CONTACT INFORMATIONwww.optimumpatientcare.org

BIOGRAPHY Professor David Price

Qualifications: B.A. (Hons) Grade 2:1, M.B B.Chir, M.A.,D.R.C.O.G, FP Cert MRCGP with Distinction

Appointments:* General Practice Airways Group

Professor of Primary Care Respiratory Medicine,University of Aberdeen.

* Sessional General Practitioner, Norfolk.* Chairman of research committee of the International

Primary Care Respiratory Group* Co-director for the Norfolk and Suffolk Comprehensive

Local Research Network* Affiliate Associate Professor, Department of General

Practice, University of Adelaide, Australia

Research Interests: Primary care respiratory diseaseincluding asthma, smoking cessation, COPD, rhinitis,respiratory infections and rhinosinusitis. Understandingclinical effectiveness of management and therapeuticinterventions.

Teaching Interests: Primary care respiratory diseaseincluding asthma, smoking cessation, COPD, rhinitis,respiratory infections and lung cancer. Understandingclinical effectiveness of management and therapeuticinterventions.

Email: [email protected]

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Improving AsthmaTreatment byIntegrated Medical CareNeil Churchill, Asthma UK

There are 5.4 million people in the UK who are currentlyreceiving treatment for their asthma, including over onemillion children. Asthma is one of biggest causes of

emergency hospital admissions and costs the NHS £1 billion everyyear. At Asthma UK we’ve been saying for many years thatimproved working between primary and secondary care is vital ifpatient outcomes are to improve; and many of our healthinterventions encourage the seamless interaction acrossorganisational boundaries between both healthcare professionalsand education professionals (when children are involved). This isbacked up by BTS/ SIGN guidelines, which recognise the need forcare to be delivered across boundaries.

Reducing unnecessary emergency admissions is a key priority forAsthma UK, underscored by the publication of The Asthma Divideand Wish you were Here? which ‘ranked’ all Primary CareOrganisations in the UK according to their standardized emergencyadmission ratios. These reports have enabled us to forge closerlinks with some PCTs to develop a strategy to tackle admissions. InBirmingham for example, we are supporting a multi-disciplinaryclinical team from three hospitals (Birmingham Children’s, City andSandwell) that are working with clinical colleagues from the Heartof Birmingham PCT to develop a joint clinical asthma care pathwayas part of their efforts to improve care. In the North West, sevenPCTs are developing asthma action plans to reduce hospitaladmissions, and NHS Yorkshire and the Humber have adopted atarget to halve child hospital admissions as part of the Next StageReview.

Action on emergency care is necessary because we know one insix people who have received treatment for an asthma attack needemergency treatment again within two weeks. It is crucial thatanyone who has suffered an admission is helped throughinformation, advice and practical support to avoid a repeat episodeof the severe attack that left them needing emergency care.Effective integration is crucial here. Primary care professionals needto know who has been hospitalised in order to ensure thateffective follow-up is delivered. Several reports, including a studyby Liverpool University, have shown that follow-up visits do notroutinely happen, and that is confirmed by our conversations withspecialist heathcare professionals. To address this challenge, welaunched an Emergency Care Pack for all healthcare professionalsworking in any setting, who come into contact with people withasthma at the time of an asthma attack. The pack details theprocess of care from when a person with asthma first presents upto their follow-up arrangements and discharge. We believe it’snecessary and feasible.

We want to ensure that asthma is given a higher priority in localplans for commissioning and delivery of health services and to raiseawareness in the sphere of asthma and self management, amonghealth and education professionals and people with asthmathemselves. Asthma UK has set up a Local Asthma Impact Projectin the North West of England with the aim of working with PrimaryCare Trusts to improve asthma awareness, control and self-management in areas of high deprivation and with particularneeds as identified in The Asthma Divide. A full time projectmanager and a part time asthma nurse specialist are working withthree local PCTs to promote awareness of asthma, agree actionplans to improve asthma services and self- management. TheNorth West Strategic Health Authority is supporting this initiativeand the implementation of action plans.

Properly targeted care can have huge benefits and produce realimprovements as seen in Dudley [case-study] where Asthma UKfunded a paediatric respiratory nurse. Whilst this service is stillbedding in, its value and impact have been demonstrated by itssteady progress against its target outcomes, such as school asthmapolicies and care pathways. Other than clinical caseload, all areasof work are now more clearly structured and defined via the

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Paediatric Respiratory Forum. Although the post is now funded byDudley PCT, without initial funding for one year through AsthmaUK it is unlikely that this post and service would have beendeveloped.

Integration needs to reach across boundaries between healthand education too. Children and young people with asthma havetold us that they have faced a battle to get on in their schools.Reports include some children being told to leave the classroombecause their wheezing was disturbing other pupils. Worryingly,young people tell us that predictable patterns of ill-health, causedby asthma, are often not understood by their schools, and childrenmay not be helped to make up for absences caused by hospitaladmissions. Furthermore, young people are often required to taketime out of school to see five or six specialist consultants, causingadditional pressure on learning time. A better, integrated approachis needed.

One of the incentives towards greater integration will bePatient Reported Outcome Measures and associated qualitymetrics. In addition to recording better health outcomes, patientsstress the importance of freedom from symptom distress as wellas optimal functioning. In other words, children want thefreedom to be able to thrive at school and pursue interests, andadults want the ability to work, to socialise, to fulfil the daily tasksof living. We all, as healthcare providers, need to get better atseeing the whole person, and not be misled by ‘process targets’which can give a very misleading impression of the patientexperience. As one young women said to me recently, ‘asthma isdestroying my life’ - a sentiment not just expressive of repeatedhospitalisations and poor functioning, but just as reflective of theconsequent loss of her boyfriend, loss of friends thanks to havingto drop down a year at school, and loss of her one passion, thepursuit of dance.

MANAGED CLINICAL NETWORKS (MCNS)There is much to learn from what is happening in other parts of

the UK too. In Scotland, Managed Clinical Networks (MCN) havebeen operating for a number of years defined as ‘linked groups ofhealth professionals and organisations from primary, secondaryand tertiary care, working in a co-ordinated manner, unrestrainedby existing professional and Health Board boundaries, to ensureequitable provision of high quality clinically effective servicesthroughout Scotland’.

Each MCN must appoint a ‘Lead Clinician/Officer’ who takesoverall responsibility for the functioning of the network to ensurethat the network is effective and achieves its aims to developequitable, high quality, clinically effective services. Each networkmust include representation from service users and the voluntarysector in its management arrangements and must have a definedstructure which sets out the points at which the service is to bedelivered, and must devise an annual work plan setting out the

intended service improvements. A report is produced every yearthat is available to the public. MCNs must seek accreditation fromtheir NHS board at an appropriate stage in their developmentand the Scottish Government advises that MCNs can helpCommunity Health Partnerships to achieve their objectives inrelation to the management of long-term conditions such asasthma. Responsibilities include development of referralpathways, treatment protocols, clinical audit and the provision ofgood quality, consistent information to service users and theircarers.

Over the last two years, Asthma UK Scotland has establishedlinks with several respiratory MCNs and their paediatricsubgroups in Borders, Forth Valley, Greater Glasgow, Grampianand Tayside. In 2008, a national steering group was set up bythe Scottish Government with representatives from all respiratoryclinical networks across Scotland that included offering fundingto set up Managed Clinical Networks where they do not alreadyexist. As key players in the respiratory field, Asthma UK Scotlandand the British Lung Foundation were invited to be members ofthis group and its working group in order to develop a workprogramme. The purpose of the national steering group is tofoster respiratory health, to improve the quality of care forpatients with respiratory disease throughout Scotland and toencourage the implementation of good practice through localmanaged clinical networks. Its aims and remit include supportingminimum common standards of care for respiratory diseaseacross Scotland and the development of a national strategy forrespiratory disease.

In England respiratory networks do exist in some places based onthe cancer model but in the absence of a national strategy forasthma in England there remains a significant challenge inattracting the interest more widely of the Primary Care Trustcommissioners. We hope that more networks will be developed infuture years, as the only way asthma care can be improved isthrough concerted efforts to design and deliver care by integratedteams working across boundaries.

DUDLEY PCT AND ASTHMA UK CASE-STUDY

Why?:• The UK has among the highest prevalence rates of asthma

symptoms in children worldwide with one in 11 children livingwith asthma.

• On average there are 2 children with asthma in everyclassroom in the UK

• Every 16 minutes a child is admitted to hospital in the UKbecause of their asthma

• 41% of emergency admissions for asthma in 2006-07 werechildren aged under 15. Admissions per head of populationwere more than twice as high for children as for adults

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The local picture mirrors the evidence base:• Based on data from the 2001 census and using a conservative

estimate of10%, in Dudley there are approximately 6,000children with asthma and 4,500 of these are of school age

• Dudley schools with an asthma register hold the names of 10-15% of the pupil population on that register and the LifestyleSurvey (2006) tells us that an average of 15% of children andyoung people from school years 5,6,8 and 10 in Dudley reporthaving asthma

• Local anecdotal evidence mirrors the national figure in termsof impact on quality of life and school absence

• Fatal and life threatening episodes of asthma amongstchildren, although rare, continue to occur in Dudley. It is feltby experts that all the recent ones were entirely preventable.

Appointment of a children’s asthma nurse specialist for one year,funded by Asthma UK, enabled the post-holder to:

• ensure many more schools within the area are activelyimplementing an asthma schools policy thus helping toimprove safety standards within schools

• provide more education and training for healthcareprofessionals such as practice nurses and school nurses

• develop and implement care pathways to improve thestandards of care

• provide a case management service for children with complexneeds.

Outcome:By the end of the year, the number of schools with asthma

policies had increased by 20% and a number of improved practicesregarding use and accessibility of inhalers within the schools hadoccurred. The 12-month period ended in November 2007 and thepost has now been made permanent by Dudley PCT with theservice continuing to develop. Other achievements include:

• The Asthma Friendly School Award has been establishedlocally in conjunction with the Health Promoting SchoolsService. This award encourages and supports schools to beAsthma Friendly and recognises their efforts and achievements

• The development of Care Pathways has become theoverarching area of work to promote seamless, high qualityhealth services for children and young people with asthma inDudley

• The setting up of a Respiratory Local Implementation Grouphas resulted in paediatric asthma becoming one of the keyareas of work.

The future:The recent NHS West Midlands Report from the Children’s

Clinical Pathway Group, post-Darzi, has identified asthma as 1 of

20 top priority care pathway areas and expressed several keymessages:

• More effective health and well being promotion is needed.• Each PCT must provide specialist services in the community

for children with illnesses or long term conditions.• PCTs must provide adolescent services.• NHS should make it easier to identify and share good practice.• Providers must work together to construct seamless pathways

and to improve quality and outcomes.• Children’s needs are paramount.• Reconfiguration of services is vital.

Therefore services need to be developed as described above andin addition to the current work of the Paediatric Respiratory Forumwill effectively meet these key messages in relation to children andyoung people with asthma. ■

BIOGRAPHYNeil Churchill joined Asthma UK as Chief Executive insummer 2007. Previously Neil has worked for the charitiesAge Concern, Crisis and Barnardo’s and the think-tank thePolicy Studies Institute. In 2007, he worked for the Councilof Special Economic Advisers at HM Treasury and has servedon several government working groups, including pensionreform, ageing strategy, financial capability, and disabilityand choice in health. He has published on healthinequalities, independent living, pension reform amongother subjects and has international experience fromVietnam, USA and Japan. Neil’s special interests arecorporate strategy, public policy and service developmentand he writes on policy and politics issues for differentjournals. He is a trustee of several charities, a committeemember for ESRC and has degrees from Cambridge andSouth Bank universities. He is a fellow of the CharteredInstitute of Marketing and the Chartered Institute ofPublic Relations.

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Respiratory Care 33

Recognising theImportance of COPD

Professor Neil Barnes

Chronic Obstructive Pulmonary Disease (COPD) has, untilrecently, been very much a Cinderella disease. Littleattention was paid by health systems, government,

researchers or the pharmaceutical industry to the problem. Thissituation has now changed. Health systems have recognised theimportance of COPD in terms of morbidity and mortality. Researchinto airways disease in the lung, once dominated by asthma, isnow actively studying COPD and the pharmaceutical industry hasrecognised the high need for new therapies in COPD and a rangeof novel treatments are being developed and entering clinical trials.

EPIDEMIOLOGYOne of the reasons why COPD has moved up the health care

agenda is recognition of how common the condition is and thecost to the health service. This is not only an issue for thedeveloped world but also for developing countries such as Indiaand China. The WHO predicts that by the year 2020 COPD will bethe third leading cause of death worldwide and the fifth leadingcause of disability. In the UK COPD is the fourth leading cause ofdeath and the second commonest cause of admission to hospitalin adults. COPD affects approximately 4% of adults. In thedeveloped world the most important risk factor for COPD iscigarette smoking. Industrial pollution of the type seen in westerncountries can only really act as a co-factor with cigarette smokingbut on its own it is not severe enough to cause COPD. There isincreasing evidence that childhood factors can increase the risk ofCOPD. Severe childhood respiratory illnesses which reduce the peaklung function achieved in early adult life increase the risk ofdeveloping COPD.

Worldwide there are other important risk factors for COPD. Insub-Saharan Africa, India and China non smoking women developCOPD and this is due to cooking using biomass fuels in poorlyventilated housing. With increasing migration this type of COPDcan now sometimes be seen in the UK in older women who grewup in the Indian sub-continent and used this form of cooking.

DIAGNOSIS OF COPDThere has always been a degree of confusion around the

diagnosis of COPD. This is partly due to terminology as thecondition has gone under a number of different names such aschronic bronchitis, emphysema, reversible obstructive airwaysdisease, chronic obstructive airways disease and, more recently,COPD. Formerly the most widely used definition of COPD wasbased on physiology emphasising the airflow obstruction and thefact that this was poorly reversible. In recent years it has been

recognised that COPD is a disease that does not just affect thelungs but other parts of the body with nutritional depletion,cardiovascular risk and osteoporosis being some of the systemicmanifestations. This is emphasised in the definition of COPD usedin the European Respiratory Society (ERS), American ThoracicSociety (ATS) Guidelines. This states that COPD is a preventableand treatable disease state characterised by airflow limitation thatis not fully reversible. The airflow limitation is usually progressiveand is associated with an abnormal inflammatory response of thelungs to noxious particles or gases, primarily caused by cigarettesmoking. Although COPD affects the lungs, it also producessignificant systemic consequences.

DIAGNOSISThere is a lot of confusion and misunderstanding about the

diagnosis of COPD. The GOLD (Global Initiative on ObstructiveLung Disease) guidelines emphasise that COPD is a clinicaldiagnosis confirmed by spirometry. Patients should usually havetypical symptoms of shortness of breath, cough and sputumproduction. There should be exposure to a known risk which inthe UK is almost always cigarette smoking and the diagnosis isthen confirmed by spirometry. The importance of understanding

Professor Neil Barnes

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this is that a diagnosis of COPD cannot be made withoutspirometry as many patients with shortness of breath, cough andsputum will have normal lung function and therefore not haveCOPD. On the other hand, COPD cannot be diagnosed purely onthe basis of spirometry as poorly controlled asthma andbronchiectasis may both cause airflow obstruction which does notreverse with bronchodilators. The role of the bronchodilator test isalso often confusing. If a bronchodilator is given and thespirometry returns to normal, or there is a very large improvement,this is indicative of asthma. However, many COPD patients willhave a small response to bronchodilator so a minor response to abronchodilator is still compatible with COPD.

CO-MORBIDITIESIt is now recognised that COPD is an inflammatory disease of

the airways. Cigarette smoking sets up a pattern of inflammationwhich is now well characterised. The predominant cells are CD-8+T lymphocytes, macrophages and, in the lumen of the airways,Neutrophils. This pattern of inflammation has a poor response tosteroids. It is thought that the inflammatory changes set up in theairways by cigarette smoking then lead on to the secondarystructural changes such as the mucus gland hypertrophy leadingto sputum production and the destruction of alveoli leading toemphysema.

COPD also has extra pulmonary effects. In more severe COPDweight loss is common. While this weight loss is multifactorial oneof the most important components is a loss of skeletal muscle due,at least in part, to reduced exercise. COPD is also a risk factor for

cardiovascular disease over and above the effects of cigarettesmoking. That is, if a group of individuals who have smoked buthave not got COPD are compared with a group who have smokedto the same extent but have COPD, those with COPD have greaterrisk of cardiovascular mortality and morbidity. COPD is also a riskfactor in osteoporosis. COPD is associated with high rates ofanxiety and depression; this is partly brought on by the socialisolation which occurs in individuals who cannot get out to visitfriends and relatives because of their impaired exercise tolerance.

OVERVIEW OF TREATMENT OF STABLE COPDThe aims of treatment of COPD are to improve current

symptoms, including improving exercise tolerance, to reduce therisk of exacerbations, to reduce the effect of the co-morbiditiesand to reduce mortality. The treatment of COPD consists of amixture of drug and non-drug treatments.

Smoking cessation is the most important intervention in COPDand whatever severity of COPD it is beneficial in terms of reducingmortality. In mild to moderately severe COPD smoking cessationreduces the rate of decline of FEV1 although it is less clear if it doesthis in severe COPD. Smoking cessation reduces the risk ofexacerbations of COPD and reduces the risk of co-morbiditiesparticularly cardiovascular problems. All patients with COPD shouldhave smoking cessation advice backed up by smoking cessationsclinics, nicotine replacement and drug treatment if required.

Bronchodilators are the mainstay of drug treatment for COPD.One of the major advances in the management of COPD in recentyears has been the introduction of long acting bronchodilators,either the long acting beta 2 agonists Salmeterol or Formoterol orthe long acting antimuscarinic Tiotropium. These drugs improvelung function, improve quality of life and reduce exacerbations ofCOPD. Even patients who do not show any response in terms ofimprovement of FEV1 to these agents may show improvements inquality of life and symptoms. Patients who remain symptomaticdespite short acting bronchodilators should be given a trial of longacting bronchodilators. Evidence is clearly emerging that for manypatients the combination of a long acting beta 2 agonist and along acting antimuscarinic agent has added to benefit. A recenttrial of the long acting antimuscarinic agent Tiotropium hassuggested it may reduce mortality in stable COPD.

Inhaled corticosteroids have been a controversial treatment inCOPD. Although widely used in the UK the evidence for theirbeneficial effect has until recent years been weak. Evidence froma range of clinical trials now indicates inhaled steroids have a smalleffect on improving lung function, improve quality of life but theirmain effect is to reduce the number of exacerbations of COPD.Evidence from the recently performed TORCH study indicates thatthey are best co-prescribed with long acting beta II agonists andthat used in this way they may also reduce mortality from COPD.

Pulmonary Rehabilitation, a combination of education and

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Cigarette smoking a basic cause of COPD

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exercise has been shown to be of marked benefit in COPD improvingquality of life and exercise capacity. National and internationalguidelines both strongly recommend pulmonary rehabilitation forall severities of COPD, but provision of pulmonary rehabilitationservices is patchy. One of the most important lessons to be learnedfrom the experience of pulmonary rehabilitation is that it is veryimportant that patients with COPD keep as active as possible.

Long term oxygen therapy is indicated in stable COPD forpatients who are chronically hypoxic. The main objective oftreatment with long term oxygen therapy is to improve survival.The available evidence is that to do this long term oxygen therapyneeds to be given for at least 15 hours a day. Most patients thinkthey are being given oxygen to relieve breathlessness; in fact theevidence that it relieves breathlessness is weak. Patients thereforetend to use oxygen on an intermittent basis and need educationabout the role of oxygen and the importance of taking it for atleast 15 hours a day.

Flu vaccination is recommended for COPD as data base studiessuggest that it reduces exacerbations. However most exacerbationsof COPD are brought on by other viral infections such as rhinovirusand adenovirus which are unaffected by Flu vaccination.Theophyllines have a very minor effect in COPD and this beneficialeffect needs to be weighed against their potential for side effectsin an elderly population with cardiovascular disease.

Mucolytic agents such as Carbocisteine have until recently beenvery little used in the UK. The evidence for their efficacy is mainlyin patients who are not taking inhaled corticosteroids and evidencethat they have an additional beneficial effect in patients oncombination therapy with inhaled steroids and long acting beta 2agonists plus a long acting antimuscarinic is weak.

Because of the frequency with which patients with COPD haveco-morbidities active attention to other conditions which increasecardiovascular risk such as hypertension, diabetes andhypercholesterolemia need to be considered.

For exacerbations of COPD the most important treatments arebronchodilators often at high doses to relieve bronchospasm andimprove dyspnoea. Antibiotics are indicated for patients withevidence of infection which is usually increased cough, increasedsputum volume and purulence. The commonest bacteria causingexacerbations of COPD are Streptococcus pneumoniae,Haemophilus influenzae and Morexella catarrhalis so logicalantibiotic choices are Amoxicillin, Co-amoxiclav, Tetracyclines ororal Cephalosporins.

Oral steroids have been shown to improve the rate of resolutionof exacerbations of COPD and shorten hospital stay. The exactlength of treatment required is not certain, but is probably in theorder of 10 to 14 days. Currently available evidence from data basestudies indicates that patients who are put on long term steroidsfor COPD have a worse prognosis and this treatment is no longerrecommended.

For patients with acute exacerbation of COPD who are acidoticwith CO2 retention and respiratory failure who do not respondadequately to bronchodilators, antibiotics and steroids, noninvasive ventilation has shown a marked effect on survival andreduction in symptoms.

FUTURE DEVELOPMENTS Future developments in COPD are likely to lie in 2 main areas.

The first is in improvements in service organisation and provisionof care allowing all patients to benefit from appropriate drug andnon drug treatment particularly making Pulmonary Rehabilitationmore available. In parallel with this a number of promisingpharmacological agents are being developed which may reducethe inflammation present in the airways in COPD. The first of thesewhich are likely to be come available are the type IVPhosphodiesterase inhibitors such Roflumilast

It is likely in the future that the management of COPD willbecome similar to that of cardiovascular disease where a range oftreatments are used, some to reduce long term risk of death andothers to improve current symptoms and reduce the risk ofexacerbations. ■

BIOGRAPHYProfessor Barnes trained at Cambridge University andWestminster Medical School qualifying in 1979. He startedspecialising in respiratory medicine in 1982, training atKing’s College Hospital and the London Chest Hospital.He has been Consultant in Respiratory and GeneralMedicine at the London Chest Hospital and The RoyalLondon Hospital since 1988 and Professor of RespiratoryMedicine at Bart’s and The London School of Medicine andDentistry since 2002. He is joint R&D Director. ProfessorBarnes’ clinical interests are in asthma, COPD, pleuraldisease and cough. His research interests are in themechanisms and pharmacology of asthma and COPD andclinical trial design and interpretation. He has publishedextensively on these subjects and given invited lectures atmost of the major respiratory meetings worldwide. He hasserved as Associated Editor for Thorax and has been on theEditorial Board of The American Journal of Respiratory andCritical Care Medicine, Primary Care Respiratory Journal andTreatments in Respiratory Medicine. He has been a reviewerfor a wide range of general and respiratory journals.He co-chairs the Pharmacology section of the evidence-based UK Asthma Guidelines. He has acted as an advisor forthe GOLD and GINA Guidelines on assembling evidence forguidelines. He is an advisor to GOLD and on the ScienceCommittee of GINA.

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Smoking Cessation36

Integrating SmokingCessation Services

Kate Spicer - QUIT Communications Project Manager

Around 10 million adults in the UK currently smoke andstatistics show that 70% of these want to quit. As eachof these smokers will have their own individual needs, an

integrated approach to helping them quit is vital to ensure thatthe right kind of support is available when they need it.

Smoking cessation provision should encompass both primaryand secondary care professionals as well as community groups,schools and a variety of other local services.

Some Primary Care Trusts (PCTs) may struggle to meet theirNHS annual targets for smoking cessation through their exist-ing services alone. QUIT®, the UK’s stop smoking charity, offersa variety of services to support PCTs to reach their targets, byencouraging an integrated approach to helping smokers to quit.

Services that could be integrated to provide stop smokingsupport include:

• Quitlines• Online Stop Smoking Advice• Stop Smoking Groups• Community Health Events• GP, Dental, Pharmacist and Optician Referrals• Workplace initiatives• Youth services• Specialised Services

QUITLINESQUIT can provide a tailormade pro-active counseling service,

offering quitline support via a dedicated freephone number foreach PCT. Some surveys have shown smokers are four timesmore likely to use a quitline than to seek face-to-face counseling,which means the quitline can be integrated into existing stopsmoking provisions, so as to cater for individual smokers’ pref-erences.

A dedicated quitline service includes stop smoking informa-tion and advice for inbound callers, and referral to a local stopsmoking group if requested. An extra option available is an in-dividual call back service to monitor a smoker’s progress andsupport them through their quit attempt on a weekly basis. Re-porting is provided on a monthly/quarterly basis.

QUIT already partners with several PCTs in the UK to imple-ment pro-active telephone support services to increase the num-ber of people quitting smoking. For example, Western CheshirePrimary Case Trust have been using a tailormade QUIT telephonecounseling service since January 1st to support their existing stopsmoking work.

ONLINE STOP SMOKING ADVICEAn integrated programme must address the different needs of

smokers and while some may prefer ringing a quitline to receivingface-to-face help, others would prefer the extra anonymity of emailsupport and website support. A quitline can easily be run in con-junction with an individual same-day email advice service.

STOP SMOKING GROUPSFor those smokers who want to share tips and advice with oth-

ers going through the quitting process, the option to access groupsupport should be available. A local stop smoking group, run bytrained professionals on a weekly basis, can help the smoker to seta quit date and access information on Nicotine Replacement Ther-apy and stop smoking treatments Zyban and Champix.

COMMUNITY HEALTH EVENTSFace-to-face stop smoking support can easily be combined with

other health promotion services, for example addressing obesity,high blood pressure and cholesterol, and diabetes. QUIT can pro-vide trained stop smoking advisors for community events or infor-mation stands, offering Carbon Monoxide monitoring, tailoredadvice and stop smoking literature.

GP, DENTAL, PHARMACIST AND OPTICIAN REFERRALS GPs, nurses, and community health workers should all be aware

of the local services on offer, so they can be confident of referringsmokers onto the most appropriate option for them.

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Pharmacists and pharmacy assistants are among the mostaccessible of all health care professionals, making them ideallyplaced to provide care and support to those who want to stopsmoking. As smoking is also linked to dental, mouth and eyehealth, dentists, dental technicians and opticians could alsoprovide very useful referrals to local stop smoking services.

WORKPLACE INITIATIVESStop smoking support should not only be the responsibility

of local health care providers, but also commercial businesses.Smoking costs UK businesses millions of pounds every year in thelost workdays of sick employees. Local stop smoking services couldoffer workplace help for smokers, providing stop smoking serviceson site, including groups and information events.

Alternatively businesses can be referred to QUIT who offer work-place support across the whole of the UK. QUIT provides fullytrained counsellors to attend a venue of the employer’s choice, toprovide stop smoking advice and information to any employee.The counselling team provide practical advice and assist smokersto identify solutions to any challenges preventing a quit attempt.Information leaflets and QUIT resources are provided to allemployees during the event and the counsellors signpost anysmoker to the local stop smoking services.

The other option is for QUIT’s fully trained stop smoking coun-sellors to provide stop smoking groups that can be held within theworkplace. The groups run for a period of 6 weeks and normallylast approx. one hour. The groups provide the ultimate tools ofsupport for employees who want to quit within a structured andshared setting. QUIT counsellors advise on and prescribe appro-priate stop smoking treatments (Nicotine Replacement Therapy)while guiding motivated employees through a series of counsellingsessions in a friendly and relaxed group setting.

YOUTH SERVICESWhile approximately 312 adults are dying of smoking related

illnesses every day in the UK, 450 young people are starting tosmoke, or trying it. An integrated approach to tackling smokingcessation must include provision to help young smokers who wantto quit, and educate young people about tobacco use to preventthe uptake of smoking.

Quit Because - QUIT’s youth service - helps young people makeinformed choices about tobacco use and provides practical,tailored support and advice to those who want to stop smoking.

The Quit Because team, who are stationed around England,already work in collaboration with key partners, including PCTs,school nurses, healthy schools, tobacco alliance groups, countycouncils and substance misuse teams. The programme isextremely flexible and can be adapted to suit an area’s strategicdirection, need and/or gap. The service can easily be run along-side adult provisions, with the potential to offer joint parent and

child initiatives where appropriate. For example, QUIT haspreviously run parent workshops in conjunction with an obesityprogramme.

The Quit Because programme is the only national independentyouth prevention and intervention project in the UK. Since 1994the programme has worked with more than one million youngpeople, aged between 8 - 18 years of age.

In addition to working in school environments, the services canbe delivered through Pupil Referral Units, Youth Clubs, teenagepregnancy groups and Connexions.

The aim of our programme is to enable young people to makeinformed choices about their smoking behaviour and de-normalisetobacco use.

The basis of our service involves:

1.Presentations: Educational presentations in schools, colleges orother youth settings are lively and interactive to capture theattention of young people. Topics discussed include myths andfacts about smoking, peer pressure, ingredients of a cigarette,the tobacco industry, and effects on health and appearance. Theyouth presenters will also discuss issues of secondhand smokeand offer access to adult services for any children worried abouttheir parents’ smoking.

2.Follow-up sessions: Follow-up sessions provide the youngpeople the chance to ask more questions and receive in-depthinformation on a more personalised basis. In primary schools,activities could include pass the parcel, body-mapping andquizzes. In secondary schools, an advice and informationstall can be provided, where young people can get moreinformation about quitting and referrals to existing local stop-smoking services.

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3.Events: Quit Because can provide a stall with information andCarbon Monoxide readings at any event happening in theschools or within the community.

4.Stop Smoking Groups: Stop smoking groups run in schools,youth clubs, and any other youth setting to support youngpeople who wish to stop smoking. The courses run for up to 9weeks and are intense interventions with groups of students.Usually run during lunch breaks, the course covers a number oftopics and support elements such as how to quit, preparation,support after quit date, Nicotine Replacement Therapy, self-efficacy and peer pressure. The groups include 4 week and6-month follow-ups, and importantly, quitters can counttowards local NHS targets.

5.Workshops: Parent workshops could be run by QUIT and/orin partnership with the stop smoking service. Other bespokeworkshops could include teenage pregnancy and youngfamilies.

6.Drop-ins: This service can provide a regular drop in schedule foryoung people to receive stop smoking information and support- in both one-to-one and group environments. Signposting andreferral to local stop smoking services is important and thedrop-ins can cover Carbon Monoxide readings, NRT advice andsupport. NHS forms can be used to record quitters.

Through all of our services, specialist support is provided toteachers and youth workers. This is achieved through Quit Becauseyouth materials - resources available to help them to discuss theissue further with young people. These include resource packs withclassroom activities, promotional resources for schools andstudents on how to access stop smoking services, and a websitededicated to young people: www.quitbecause.org.uk.

SPECIALISED SERVICESIn order to be able successfully to tackle smoking cessation,

services need to take on board other issues that may play a part inthe reasons why people want to quit, or the problems they mayencounter when making a quit attempt.

For example, QUIT launched a specialized service - QUIT Now -to help smokers with mental health problems. These smokers aretwice as likely to smoke as the general population. All health pro-fessionals can refer community mental health patients onto theproject.

In partnership with the Sainsbury Centre for Mental Health, andfunded by Cancer Research UK, the QUIT Now project offersspecialist, tailor made stop smoking support to smokers withsevere and enduring mental health problems through proactivetelephone counselling.

Research has shown smokers with mental health problems dowant to stop smoking but also that they need the right kind ofsupport. The telephone counselling service has been developed to

enhance existing cessation services and address the specific needsof smokers with mental health problems.

Referral is via a form available on www.quit.org.uk/healthpro.php or by calling Quitline 0800 002200 whilst with thesmoker. QUIT counsellors will provide an intensive proactivetelephone counselling service to the smoker. A provision of sixtelephone counselling sessions will be made available which will bediarised at appropriate and convenient times through the quitattempt.

All smokers accessing the service will receive free motivationalresources, including the QUIT Guide to Stopping Smoking andMental Health, to support the quit attempt.

QUIT TRAININGQUIT can provide training for any health professional on a wide

range of topics from helping smokers to quit, to helping youngpeople, lone parents and pregnant smokers: and relapseprevention, motivational interviewing and smoking and depres-sion. As smoking cessation is not currently a compulsory elementof medical training, these courses can provide a wider base ofknowledge and skills, and help professionals understand some ofthe wider issues surrounding smoking and the difficulties peoplecan face when trying to quit. This will reinforce the importance ofintegrating services to make sure all the needs of smokers in yourarea wanting to quit are met. ■

BIOGRAPHYKate Spicer is Communications Project Manager at QUIT®,the national stop smoking charity. She has been part of thecommunications team at QUIT for more than three years,having previously worked as a sub-editor at thePress Association. [email protected]

For more information about the services QUIT provides forPrimary Care Trusts, QUIT training courses, and QUITworkplace initiatives, please contact Paul Rossiter on0207 553 3268 or [email protected] for moreinformation.

For more information about the QUIT Because youthprogramme, please contact Anne Schulthess on0207 553 3269 or [email protected] for moreinformation.

Quitline 0800 002200 email:[email protected]

Smoking Cessation38

Integrated Care

Child Care Services 39

Meeting ComplexNeeds throughSpecialist Provision Matt Vince, Director, The Lioncare Group

In recent years, residential child care in England has been underscrutiny and attack, variously referred to as too expensive, ofpoor quality, and a measure of last resort. There is a clear bias

in central and local government towards promoting foster care asthe Provision of First Choice for Looked After Children. Foster care,it is argued, provides children with the opportunity to experiencefamily life, family values, and prevents them from becoming insti-tutionalised.

Foster care is unquestionably a positive placement choice formany Looked After Children. The quality and provision of fostercare has undergone extensive change and improvement in recentyears, offering many children and young people excellent out-comes and a stable home life.

However, while foster care may be the right choice for the ma-jority of Looked After Children, it is not always the right option forall Looked After Children. This point is highlighted by the ScottishInstitute for Residential Child Care which states “some young peo-ple may have little support from their families, yet their family con-nections remain important and they have no desire to be fosteredor adopted, even if that option was available”.

In her report titled ‘Handle with Care! : An investigation into thecare system’ (2006) Harriet Sergeant states, “Children’s Homes aretheir last chance before secure accommodation”...’We put chil-dren into a placement knowing it’s not right for the carers or thechild. But we have not got anywhere else. We set them up for fail-ure. But what else can we do with that child?”

The answer is, that for a small but significant number of LookedAfter Children, quality therapeutic residential care and interven-tion, delivered in a planned, informed, and considered manner,must now be accepted as a Positive Choice;

David was known to his Local Authority since the age of 1, whenhis mother stated that she was unable to cope with caring forhim due to her own mental health issues. She presented asneeding emotional support. David’s schooling changed fre-quently. His mother took several overdoses after having suicidalfeelings. She become “more erratic and self destructive” andDavid was witness to her rapidly declining mental health. He disclosed that his mother was physically violent towards himcausing him to regularly hide in the bathroom. He also said hismother’s daily drinking had made him very scared. The schoolconfirmed these statements through observing the mother re-acting very aggressively to David for minor misbehaviour. The Local Authority became increasingly concerned aboutDavid’s safety and emotional wellbeing as the effects of

chronic neglect became more evident. At school, David pre-sented as angry and verbally aggressive towards his mother.During home visits, David was observed to be beyond the con-trol of his mother who admitted to resorting to locking Davidin his room as a punishment. A Social worker witnessed themother asking David a number of very inappropriate and lead-ing questions of a sexual nature; David consequently had aninappropriate knowledge of adult sexual matters for his age.Eventually, David said he wanted to be taken into care becausehe hated his mother, she didn’t feed him, she didn’t give himpocket money and she beat him. David experienced multiplebreakdown of foster placements throughout his formativeyears, surviving a ‘yo-yo’ like pattern of repeatedly beingplaced with foster-families then returned to the care of hismother then placed in another foster family and so on...Heeventually sprayed deodorant in the face of his last foster carerand was then deemed to be too great a risk to be fosteredagain.

Professionals in Social Care, Education, and Health are increas-ingly acknowledging the benefits of offering specialised thera-peutic residential intervention and treatment as a measure of FirstResort to younger children with complex needs whose raw expe-rience of abuse, trauma, and neglect demand immediate provi-sion if the child is to have any hope of reaching recovery andregaining their childhood. Withholding such provision until thechild has reached adolescence and is displaying mental healthproblems and engaging in criminal behaviour is arguably immoral,anti-social, and unethical.

Integrated Care

Child Care Services 41

“Too frequently, rather than looking at the needs of a child, staffwill try various options in sequence, starting with less specialistfoster care. If this fails, then a series of moves are likely through dif-ferent types of foster care before different types of residential careare tried. We argue that assessment should be used to provide aplan for a child, which might in some cases, lead to some childrenbeing placed, appropriately, in a residential home at an earlierstage” (Clough, R., Bullock, R., and Ward. A, ‘What Works in Res-idential Child Care?’ 2006)

Research by leading figures in the field of child care has foundthat “the children who move into residential homes and schoolsas a consequence of social services intervention are likely to facepervasive problems that have not been easy to manage in othersettings”. (Clough, R., Bullock, R., and Ward. A, ‘What Works inResidential Child Care?’ 2006)

The primary task of The Lioncare Group, and similar child-careorganisations offering therapeutic residential and education in-tervention, is to help children come to terms with areas of theirlives where they experienced overwhelming difficulties, consoli-date and support areas of functioning, promote education andlearning, and enable them to move successfully to sustainable andenjoyable fostering placements or live independently in their localcommunity.

We recognise that something in the early experiences of the chil-dren we work with was not ‘good enough’ and this has preventednot only their early emotional needs being met but also their abil-ity to function in day-to-day life. They present as being trauma-tized, emotionally deprived, and damaged through theirexperiences during their early stages of infancy and childhood. Formany, the past is still part of their present. Previous negative andabusive experiences prevent them from learning, enjoying andachieving. Without appropriate early intervention, these childrenface the prospect of suffering mental health problems and / or be-coming criminalised throughout their adulthood.

These children often deal with situations in a state of panic andrage, displaying high levels of anxiety, violence, despair, and dis-sociated cognitive processes.

They often show extreme difficulty in achieving basic trust inadults, and generally find the demands of every day living over-whelming and unmanageable. They have often formed an array ofdefensive mechanisms which have proved effective in protectingthem from the outside world, but which now represent a barrier tohealthy emotional development. They may frequently display anti-social, withdrawn, disruptive, and destructive behaviours and out-bursts, and their chaotic inner world may leave them with a senseof worthlessness, emptiness and extremely low self-esteem. Theymay also show signs of learning and developmental delays.

Our practice is based on the Therapeutic Community Approach,informed by an understanding of Bowlby’s theory of attachment,the work of D.W. Winnicott, psychodynamic, psychosocial, andsystems theory, and models of good parenting. We provide a safeand secure “emotionally holding” group-living environment inwhich the child is supported in developing “good enough” at-tachments to adults, enabling them eventually (when they areready to do so) to explore the realities of the outside world inwhich they live. As these relationships develop, the child is exposedto alternative ways of living & relating through their daily care andeducation, and is enabled to practice these alternatives until theyhave internalised them sufficiently to function more independently.

The Therapeutic Community Approach promotes developmentof a living space (the facilitating environment) which has the feelof ‘a family home’ without the pressures of family living, is sensi-tive to the needs of the individual child and the group in whichthey live, and which can accommodate their changing needs asthey mature and develop.

We help children incorporate a positive experience of “goodenough” parenting and care that can facilitate repair of the dam-aged caused by previous abuse. We recognise that the healthy de-velopment of any child greatly depends on the availability of “goodenough” care, together with the provision of appropriate modelsof individuals, relationships and situations. We are also aware ofthe importance of providing children with opportunities to expe-rience different ways of relating, living and learning.

Integrated Care

42

Adults caring for and educating the children consciously usethemselves to develop appropriate relationships with, and be-tween, the children in their care and with / between other adultsinvolved with the child. Through teamwork, adult carers provide aplanned environment and predictable pattern from day to day,thus establishing a reliable structure of emotional containment forthe children. This ensures the conditions exist for the child to ex-perience having their genuine physical, emotional, social and psy-chological needs met. The approach allows us to offer childrenwho have suffered from previously damaging experiences, a spacein which they may have a secure sense of childhood, where theywill have stability of self and placement, be offered good relation-ships, be respected and be offered a model for respecting others.

Anne came to us 11 months ago from a long-term foster place-ment. While she was happy there it had become apparent thatAnne was stagnating, locking herself away for long periods oftime and displaying a deep denial of her past traumas. Anne hadbeen sexually abused by members of her family and had subse-quently miscarried. Those involved with Anne were facing thevery real possibility that she would never move on from thistrauma and would remain a “Frozen Child”. The decision wastaken for Anne to be looked after by The Lioncare Group whereshe would have access to a planned therapeutic group-living en-vironment.Since her arrival, Anne has made astounding progress in allareas. She has been encouraged to develop the unique aspectsof her personality, indulging her passion for horses with ridinglessons and work experience. She has also been entered forGCSE examinations and is expected to do well.Crucially, Anne has also begun to confront and discuss her trau-matic past. Through the combination of individual psychother-apy and adult guidance she is at last accessing the feelings ofloss and pain associated with her abuse and the loss of her babyand family. Now that Anne has become ‘unfrozen’, the focus ison helping her come to terms with these feelings, establishinga dialogue with her family regarding her past experiences, assisther in trying to make some sense out the none-sense from be-fore, and encourage her to engage with the real world whichshe previously found overwhelming. ■

CONTACT INFORMATIONMatt VinceDirectorThe Lioncare GroupLioncare House58a Livingstone RoadHove BN3 3WL

Email: [email protected] Office: 01273 720424Fax: 01273 720836www.lioncare.co.uk

Child Care Services

Integrated Care

Building and Design 43

Leading the Waywith Integrationof Services andSustainabilityKentish Town Health Centre, Camden & Islington Community Solutions Ltd.

Is it private housing, an advertising agency, a gallery? No. It isKentish Town Health Centre (KTHC). These exceptional premisesare delivering a step change in both staff and patient

experiences of the NHS. Many can hardly believe this centrereplaces its dilapidated, now demolished, predecessor. Enteringalongside an enormous 8 metre long ‘lightbox’, enclosing iconson health issues which are then repeated as 6 metre high graphicson the interior walls, you could be forgiven for not expecting yourGP or Health Visitor to appear to greet you. They do.

KTHC sets a new standard for the NHS. The partnership of a localdesign champion, Allford Hall Monaghan Morris (AHMM)architects, and Camden & Islington Community Solutions (an NHSLIFT public private partnership between Community Solutions forPrimary Care, Camden and Islington PCTs and Community HealthPartnerships) has delivered a building where design delivers theintegration of services as never before.

The project champion, Dr Roy Macgregor, initiated a RIBAcompetition for the building won by AHMM. Dr Macgregor’svision was to create a wonderful building where not only medicine,but also health and art, came together for the community. Thearchitects embraced ideas of transparency and connectivity andthe whole team worked collaboratively to create a building thatexpresses the new, holistic approach to healthcare as well as beingsensitive to the pre-existing architectural vernacular.

Located in Bartholomew Road, London NW5, the completedKTHC creates a bold civic presence that responds to itsenvironment. Referencing the brick and stucco, and architecturalrepetition, scale and forms of the surrounding housing, theground floor is articulated as a brick plinth, with the renderedforms of the upper floors floating above. Cantilevered rooms atfirst and second floor provide substantially larger floorplates atthese levels whilst allowing a small ground floor footprint andreducing the overall massing of the building.

The building is essentially of concrete construction with a steelupper floor, and consequently achieves high thermal mass. Thematerials and fit-out elements of the building have been selectedto be both robust and highly flexible. Within all rooms a hangingrail system allows everyone to customise their space from a wideselection of fixtures. Also, the use of interchangeable IPS panelsallows the switch from clinical to counselling use with green, blackand white selected to provide a calming, neutral environment.Similarly, three modes of lighting can be selected by the GP orcounsellor to suit best the needs of the patient. Within communal

areas a cost-effective lighting strategy has been designed toreinforce the linearity and volumetric nature of the spaces.

In addition a number of sustainable features have beenincorporated within the design of the building, including use ofrecycled materials and low energy options wherever possible. Theventilation is a combination of mechanical and natural, with allrooms having specially-designed opening windows that can be leftopen but secure to take advantage of night time cooling. Also theatrium creates a stack effect within the main area, drawing freshair throughout the building assisted by wind catchers, andtemperature-responsive openers on the rooflights. Solar reflectiveglass and blinds are installed throughout with terrazzo floor tilesin the main area, which absorb heat in the summer months, andby virtue of under-floor heating become a thermal store in thewinter. Grey water harvesting is used for irrigation.

Staff and patients are encouraged to embrace the sustainabilitymindset with the implementation of a Green Travel plan. There isno patient parking except for DDA bays, private use of cars isdiscouraged and staff showers are provided in order to encouragecycling to work. Four charging points for pooled use electricvehicles and thirty-eight cycle racks are installed in the staff carpark; recycling points are located throughout the building.

Integrated Care

Internally, the building has been designed around the concept ofa street - the travertine stone floor glistens and catches the lightfrom the 16 huge thermostatically controlled roof lights bringingshadows and light down through the atria and light wells alongthe internal street. Reaching the reception, huge flowers hoverover four receptionists at a unified reception desk, greeting andguiding patients. There is no visual graffiti, no notices - insteadthere are volunteers and others to ask. The centre allows easyidentification, from any one point where each service is located. 4LCD screens have been chosen to inform on events, programmesand services.

While waiting users can enjoy not just a café for the coffee andpaninis, but also an internet café, a health pod which uploads self-taken readings of blood pressure and weight to the GP - beforeyou reach the consulting room. Self check-in saves any wait atreception; and there is always the ‘secret’ secure garden doublingthe size of the waiting room under tree cover, directly outside. Offsub-waits and staff areas there are eight external terraces ondifferent levels, providing respite for stressed patients, and staff, -recently used by patients awaiting crisis team assessment. Strikingmega-graphic signage helps way-finding, which is made easier bythe visible connection of all spaces to the waiting room andcirculation space.

Circulation and waiting areas visually connect the different floorsand spaces and staff can communicate by talking from bridgesand leaning through hatches between consulting floors. Generousstaff accommodation, special tea points and break out areas meanthat different staff groups can easily meet to discuss and liaise

about clients to avoid replication and unnecessary appointments.Also people using the building have commented on the fact asthey wait they can see all the different services in action - makingit feel very friendly and lively and unlike most other large-scalehealth buildings. The flexible community space provides interlinkedrooms - not standing alone - but connected to a discreteconsulting and immunisation area, with private breast feeding orcounselling room adjacent. This has allowed an effective doublingof health visitor and doctor baby clinic provision. It has relocatedfrom a remote geographically isolated session that was poorlyattended. Improved immunisation rates are easier to achieve.

Choice of services has increased dramatically with improvedaccess to patient diagnostics, breast screening, psychologyservices, nursing, health visiting, baby clinics, communitydentistry, and planned children’s facilities. Increase in attendancefigures speak of easier access and acceptability. Bookings byexternal organisations of shared meeting room space areincreasing weekly. The centre boasts a conference suite of 6 roomsearly stakeholder work led to no service having their own room.Meeting rooms are pooled and provide a community, NHS, andstaff, flexible facility. The staff library provides a 10 terminaltraining centre, with 3D virtual learning environment planned.There is also a multi-faith prayer space.

Much has changed since this project began in 2002, not least aperception that the sustainability agenda within the NHS and otherpublic sector organisations needs to be addressed as part of thenational climate change agenda. Kentish Town Health Centre notonly leads the way from a sustainability point-of-view, but it alsoprovides an uplifting, inspiring environment of high quality forusers and staff delivered through the LIFT procurement process,setting a new standard for modern health care provision. ■

CONTENT INFORMATIONJanet Davies General Manager Camden & Islington Community Solutions

Chancery Exchange 10 Furnival StreetLondon EC4A 1AB

Tel: 0207 092 3350 DDI: 0207 092 3320 Fax: 0207 092 3351 Mob: 07890 678 871

Web: www.cicommunity-solutions.co.uk

Building and Design44

Integrated Care


The Credit Crunchand Primary Care

Colliers CRE

Primary healthcare delivery is fast becoming one of the mostinteresting property investment classes. The market is mov-ing away from the traditional range of premises (GP part-

nerships, pharmacies and dental practices) towards a ‘one-stopshop’ approach offering a comprehensive health retailing service.

The credit crunch has not had a noticeable impact thus far, withbanks generally considering healthcare properties to be a haven.Investors continue to show an interest in primary care properties;the market is less volatile with leases of 20 years plus common-place. APMS is pushing towards shorter, more flexible sub-leases,such as a five year contract. The introduction of shorter leaselengths and break options will bring the sector in line with the bulkclasses (e.g. retail, offices).

The main banks in the sector are quoted as lending at 100%loan to value, but this is subject to affordability tests. Banks re-main positive and upbeat. Investors remain concerned about al-ternative uses of the building, which are restricted by the nature ofprimary healthcare properties. Furthermore, shorter lease lengthsmay deter investors and healthcare will no longer be seen as ahaven.

HOW IS PRIMARY HEALTHCARE PROPERTY CHANGING?Replacement and upgrading of premises, along with recent pol-

icy shifts, are driving change in the primary care sector. The NHSPlan (2000) states 80% of diagnostics that could currently be con-ducted in primary care are still done so in hospitals. In addition, by2010 migration of hospital services will result in 40% of outpa-tient work moving to primary care services.

There continues to be a large proportion of premises that needupgrading or updating. The refurbishment target of 55% set in2005 by the NHS Executive was due to be reviewed in 2008 al-though there has been no update on this. In addition, co-locationwith other service providers will require new building and biggersites (3,000 - 5,000 sq m). These could include pharmacists anddentists, hospital outpatient service providers, corporate serviceproviders, day care surgery, retail, professions aligned to medicineand diagnostics.

The UK’s largest ‘one-stop’ centre has recently been completedin the spring. The 140,000 sq ft facility based in Aldershot catersfor three NHS trusts and will incorporate three GP practices and anArmy medical team.

New ‘Health Building Notes’ are currently being formulated, butwill embody three principles:

1.Multifunctional standardised space;

2.New standards of space efficiency minimising over capacity andunder utilisation; and

3.Buildings that are adaptable to the range of services they willhave to provide.

THE EVOLVING FACE OF HEALTHCARE IN THE UKIncreasingly, NHS provision sits alongside that from corporate

providers. The independent sector is being encouraged to take onnew premises and offer new services. There are already a variety ofcorporate service providers in existence. United Health works as anAPMS company to provide GP services to London, for example,whilst Virgin Healthcare has recently enjoyed a high profile launch.

The developing healthcare model in the UK aspires to that seenin Europe and the US; one that is moving from being reactive to amore proactive approach, with diagnostics and screening becom-ing increasingly important.

RISKS1.Government funding availability:

• Continuance of Notional Rent Assessment?• System of funding changes?

2.Global healthcare funding: PCTs have to balance budgets;3.Government policy shifts: who will fund and own premises in

the future?

Adam Thompson, Director – Primary Care, Colliers CRE

Integrated Care

Building and Design46

4.Who will be the tenant - GPs, PCTs or APMS?5.Lease lengths: APMS are pushing for a five year contract, so are

unwilling to take leases of 20 years plus.

OPPORTUNITIES1.Mixed use developments needed to form sustainable communi-

ties;2.Obtain land at a discounted price by way of Section 106;3.Create larger, flexible multi-tenanted investments;4.Partnering with other providers of primary care;5.Greater utilisation of accommodation optimises income.

OUTLOOKThe Government is keen to transfer medical services from hos-

pitals and secondary sources to primary healthcare services, whereappropriate, whilst at the same time consolidating community

services. As such, there is increasing demand for flexible qualityprimary care premises.

There is likely to be consolidation of practices in order to gainmore critical mass through size of patient lists, with the number ofsmaller practices likely to reduce as a result. In order to be a highquality provider, there will be a need for high quality premises as theGovernment looks for a competitive, contestable environment. Itsaim is to provide access and choice for patients throughout the UK.

The current backdrop of regulatory reform means that many sta-tistics quoted are moving targets and will be reviewed in 2009. ■

Please visit our website for further details and case studies:www.collierscre.co.uk/healthcare or call Adam Thompson on+44 20 7344 6957 / [email protected]

COLLIERS CRE HEALTHCAREEXPERTISE IN EVERY ASPECT OF THE

HEALTHCARE AND LIFE SCIENCES SECTOR

With a team of highly experienced professionals, Colliers CREHealthcare provide a range of services including:

� valuation� investment� due diligence� agency� consulting

Working with Colliers CRE Healthcare can provide a gateway toother specialist teams in Colliers CRE including BuildingConsultancy and Rating, plugging into other service lines as andwhen we need to. Being part of Colliers International means we candraw on a global support network if ever it's required.

Contact:Adam Thompson, Director+44 20 7344 [email protected]

Integrated Care


The Right Building inThe Right Place

Primary Asset

Over the last 2 years following the demands of the new NHSPlan and the interim report by Lord Darzi the form andshape of primary care buildings has changed dramatically.

The key features are now embodied by fully understanding thepotential future need of each health community. In the past thishas been shaped by largely a reconstruction and repetition of abuilding that has worked well over the years. That has all changedand the need for the health service to integrate, co-locate andagainst strong evidence base to redesign services places and focusthese and other demands on the designers and providers of newbuildings. Primary Asset Ltd, part of the MedicX Group, is com-mitted to ensuring excellence in primary care premises delivery.

CONCEPTThe key elements to any new building can be summarised as

follows-

1. A clear and concise understanding of the existing services, andthe requirements of the primary healthcare team.

2. An in depth understanding of the Primary Care Trust (PCT)plans and service strategy alongside the financial constraintssurrounding any new potential development.

3. A wide understanding of the local demography of the area,the current and future population growth as well as thedisease and deprivation profiles driving health need.

4. An integrated approach to understanding the potential needsof the community, secondary care and other service providerswho can bring value and service addition to the new site.

5. Of particular importance on each new building is the possibil-ity of integrating pharmacy services again adding value forpatients and responding to the position of the pharmacist asa key member of the primary care team.

6. The final and key driver behind every project is site selection.Often the hardest part is finding the right location that isaccessible and has sufficient parking with potential forexpansion in the future.

DESIGNOnce all the key drivers have been assimilated the design of the

building can begin involving all the key stakeholders. As practicesseek increasingly to co-locate so achieving economies of scale anddelivering a flexible structure for potential future merger is impor-tant. Working with the practice to look closely at working patternsand ensuring that the new building will work even better is para-mount. Understanding service aspirations is key as practices seek

out the space and facilities they may need often radically changethe early designs.

Close consultation with the community is critical, and the PCTneeds to understand that all potential stakeholders have theopportunity to add value to the debate that will shape a corecommunity asset for the next 25 years.

CONSTRUCTIONAs soon as the design and site are agreed then appraisals con-

figure the affordability and the resulting notional rents for whichwe seek agreement from the DV. As long term owners of thesebuildings, it is essential that the quality and durability of the build-ing is at the highest level. At the same time value engineering looksto ensure that the building is sustainable, has the most effectiveenvironmental impact and remains energy efficient.

Primary asset works closely with all potential occupiers to keepthem informed and updated during the build stage. Newsletterare produced and Primary Asset’s interactive website also chartsthe progress of the project.

A smooth transition into the new premises is crucial and supportis given to the new tenants to ensure disruption is kept to aminimum.

Wollaton Park Medical Centre

Integrated Care

THE LIFE OF THE NEW BUILDINGOnce the building is complete Primary Asset remains involved in

supporting the practices.Making best use of the building, ensuring that potential income

streams are maximised and supporting business planning are keyto ensuring that the practices flourish. Primary Asset ensureseverything works from day As services develop we can supportengineering and building needs.

Primary Asset has a dedicated property management team whoare available 24 hours a day to support the building once it hasopened-supporting the team in what is often a far more complexand larger building than before.

We support a number of sustainable features within ourbuildings, these include CO2 monitors in consulting rooms, correctventilation at all times with automatic venting and a master switchpowers down all non essential power use when the building isunoccupied ensuring a 25% reduction in power costs.

Primary Asset has a commitment to constantly improving thebuildings it delivers. We commit that we will always carry forwardthe best five features of our newest building and remove anyfeatures that fail to live up to our exacting standards.

Long term relationships with our tenants are crucial and we arethere to support our GPs if problems arise. Primary Asset aredetermined to help deliver the best possible integrated primarycare by enabling the correct design and structure through effectiveconsultation and research from the very start. Operating fromthree regional offices we know and understand the opportunitiesand challenges at a local level and are well placed to delivermarket leading solutions. ■

CONTACT INFORMATIONPrimary Asset (part of the MedicX Group)5 Godalming Business CentreWoolsack WayGodalmingSurreyGU7 1XW

Tel: 0808 202 5461Web: www.primaryasset.comEmail: [email protected]

Building and Design

Wollaton Park Medical Centre

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Been thinkingabout new premises?Primary Asset is a leading developer of innovative healthcare premises to the primary care sector.

Our vision is to create a better primary healthcare experience.

Primary care is changing rapidly, providing the opportunity to

deliver a wider range of services and create a better experience

for patients.

We believe a new facility can be the catalyst for positive change

and benefits can be maximised through partnership, teamwork

and mutual trust. We look forward to working with people who

share our philosophy and desire to make a difference.

Share your vision of the futureCall us on 0808 2025461www.primaryasset.com/beenthinking

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