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Do ‘People Pathways’ improve integration?

Do ‘People Pathways’ improve integration?

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The people who are best placed to ‘integrate’ health and care are the people who use the service, argues Merron Simpson

Whether your definition of integration is vertical (integrating primary and secondary care) or horizontal (integrating health, care and housing), well-established systems with their own built-in incentives and rewards make it difficult for professionals embedded within them to fully integrate the services they are ‘responsible’ for. I’m optimistic that progress can be made to streamline our systems so that they work more fluidly together, and I think we will move faster and stand a greater chance of success if each profession makes patients/customers/residents the focus of their activity.

People using health, care and wellbeing services don’t necessarily see the boundaries that professionals see and when they do, it is usually because of their past experiences of receiving care within a disjointed system. Evidence suggests that the NHS falls down at the point at which individuals need to move between the silos. Instead of shifting between the silos through ‘referrals’, enabling people to put together their own individualised ‘package’ and draw the right combination of services (from hospitals, their GP surgery, care providers and a variety of community providers) to themselves makes a lot of sense. People themselves can do a lot to manage their health and they usually know what will make their lives work better.

Recently, I have been putting about the idea of replacing Care Pathways with ‘People Pathways’ particularly for people managing long-term conditions: I mentioned this idea in a Tweetchat to crowd-source the NHS Alliance’s submission to the RCPG Inquiry into Patient Centred Care, with housing colleagues at the National Housing Federation Care and Support Conference, and in a debate with NHS Alliance colleagues and the Foundation Trust Network. So far, I have had positive noises from all angles suggesting a wide recognition of the limits of traditional Care Pathways that address people’s medical conditions, but overlook the person as a whole.

What if each individual living with one or more LTC was supported to develop their own personal ‘People Pathway’ containing the necessary medical elements and other things that are important to them as individuals. It could also include things the individual agrees to do themselves to promote good health and make their lives better. Providing patients with access to their health records is an important first step to create this jointly produced plan, but hospital consultants and GPs would only need to be responsible for certain (mainly medical) elements; a third party (community partner) would work with the person to help them to define other elements and access a range of relevant services available in the community. People pathways might include, for example:

 - Medical elements: eg, tablets to be taken, treatment, medical procedures in surgery or hospital

 - Nursing elements: eg, help changing dressings, home dialysis

 - Care elements: eg,  home visits, personal care

 - Social elements: eg, befriending schemes, special interest groups eg. knitting, fishing

 - Housing elements: eg, fixing boiler, putting in downstairs toilet, moving to more suitable home

 - Practical elements: eg, dog-walking, help filling in forms, cleaning, gardening

 - Exercise elements: eg, Tai Chi, gym

 - Advice elements: eg, financial and benefits advice, will-making, housing options

 - Self-management: “I will test my blood sugar level twice a day and report to my GP if it is under/over a certain level”, “I will avoid foods that are high in cholesterol”

People Pathways containing only things that really matter to the individual and moulded around them would span health, care, support, housing, community and the patient themselves in a single plan. While the individual would be in the driving seat, they might ‘access’ several different types of statutory, voluntary, and community-based organisations such as Age UK, Citizen’s Advice, Home Improvement Agencies, social enterprises and local businesses. This wouldn’t change the way services are paid for or who pays, except that it would bring funding streams together into a single plan that makes sense to the individual. Something similar, the Self-Directed Support Plan, already exists for people in receipt of personal care budgets. People Pathways would be much broader – they would contain medical (current Care Pathway) as well as other elements and they would be for anyone with a long term condition, irrespective of their eligibility for funding.

I suspect that Simon Stevens’s recent announcement about personal health and social care budgets may be partly to persuade medical professionals that their patients (and not themselves) are the real experts on how they can live their lives well. Also, that the medical model of health, the domain of the NHS and doctors in particular, is not the only vehicle through which people get well and stay well. Other things, apart from medication, treatments and personal care, matter to people and can make all the difference for someone living with a long-term condition between living a miserable or a full life.

But PHBs are contentious and the downsides have been well documented. Could ‘People Pathways‘ which focus first on how people want to live their lives and second on who will pay for the various elements be a more constructive vehicle for integrating across silos and improving people’s experience of ‘the system’ as a whole?

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Comments

Just recently I have been involved in trying to keep various teams around an elderly friend who developed an acute back, integrated in order to keep her at home. Such a pathway is essential. The idea of a People Pathway is excellent. The only problem is how does one do that with a person with dementia who lives on their own?

There is a great deal of common sense in this article. I have been experimenting with Business Process Analysis and Re-engineering methods applied to people pathways. I believe that an "Integrator" (who may be the Intelligent Person [analogous to the concept of the Intelligent Client in the procurement paradigm] - or who may be a person commissioned to act as Integrator) is essential to facilitate access to, and effective interaction with, all services.

However, by just focusing on the person as a patient and looking at what happens in all but the most acute pathways I find that the major problems are:

1. Delays between episodes
2. Failure to transfer relevant data between episodes
3. Repetition of diagnosis and analysis episodes
4. Multiple episodes that could be compressed into a single episode
5. Defining and framing episodes by reference to the clinician's role rather than the patient's needs

Applying the principles of:

- Complete resolution of an issue during the first presentation.
- Horizontal compression to reduce the number of episodes
- Use of modern data transfer methods to reduce delays between episodes
- Vertical compression achieved by multi-skilling resulting in decisions being taken by the least expensive practitioners

We could reduce the time and cost of pathways whilst improving the quality of outcomes.

In short, a patient needs:

A diagnostic episode, which may well be best executed by the patient themselves, aided by the internet, or which the patient might prefer be carried out by a competent "Diagnostician". The diagnostic episode terminates in a decision that may lead to advice, treatment, therapy, or referral for surgery. Too often at preset, the diagnostic episode is subject to a series of internal delays. For example;
Patient visits GP with a complaint
GP advice - Make an appointment for a blood test.
Delay
Give blood
Delay
Results received by surgery
Delay
Patient notified and asked to make an appointment
Delay
Patient seen by GP again and referred to a consultant
Delay
Notes sent to consultant by post
Delay
Appointment made with consultant

and so on.

In a free market, the intelligent patient would pay to make an appointment with a diagnostician who could arrange for bloods and analysis to be done on the spot and who had the authority to commission the necessary clinical course of action immediately.

My conclusion is that we must redesign our NHS to function as efficiently as a modern airline - and if that means we should all pay a nominal sum for each compressed episode so as to throttle demand, then that is what we should do.

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