Integrated care

Merger of Ealing PCT’s provider services arm, Harrow PCT’s provider services arm and Ealing Hospital NHS Trust

Posted on December 18, 2009. Filed under: Arm's length providers, Integrated care, Reports/papers |

Co-operation and Competition Panel | accessed 18 December 2009

Ealing PCT’s provider services arm, Harrow PCT’s provider services arm and Ealing Hospital NHS Trust are proposing to merge to form an Integrated Care Organisation.

Consistent with its draft interim merger guidelines, the CCP will examine the costs and benefits of the proposed merger to patients and taxpayers, in order to ascertain whether it is consistent with Principles 9 and 10 of the Principles and Rules of Cooperation and Competition.

In doing so, the CCP will consider the effect of the transaction on patient choice and competition for community or secondary health services in Ealing and Harrow or a wider area.

The CCP would welcome submissions in writing from interested individuals and organisations on this issue or on any other matter relevant to the CCP’s assessment of this transaction under the Principles and Rules of Cooperation and Competition. To submit evidence please email Ealing&

The closing date for submissions is 8 December 2009.

Case documents

Notice of Acceptance (02/12/09) [243 KB]

Administrative timetable

Event Date
CCP publishes Notice of Acceptance 1 December 2009
Closing date for Phase 1 submissions 8 December 2009
Deadline for completion of Phase 1 * 29 January 2010
Deadline for completion of Phase 2 (if required)** 24 May 2010

* At the end of Phase 1, the CCP will either:

  • recommend that the merger be allowed to proceed, or
  • recommend that the merger be allowed to proceed subject to measures agreed with the parties that address concerns identified by the CCP during Phase 1, or
  • proceed to a more detailed Phase 2 investigation.

** Phase 2 allows the CCP to conduct a more in-depth investigation where this is required to fully assess a merger.

NB. This timetable will be updated as required during the course of the inquiry.

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The future of West Essex Community Health Services

Posted on October 26, 2009. Filed under: Arm's length providers, Integrated care, Providers, Reports/papers, Social enterprise |

NHS West Essex Community Health Services | September 2009 | accesssed 26 October 2009 (pdf)

West Essex Community Health Services (WECHS) is the current provider arm (arms length trading organisation) of NHS West Essex. 

What is a social enterprise?

Social enterprise is a “badge” that a company or charity can adopt that brings certain benefits and says certain things about the ethos of the business. 

The key defining characteristics of a social enterprise are that it is not for profit, it works for the public benefit and any surpluses it makes are re-invested in the organisation. Beyond that social enterprises can be modelled in different ways to support the specific aims and purpose of the organisation. 

What all social enterprises share is an enterprising, innovative, business-based approach to achieving social and environmental aims.

A social enterprise can access monies through the Social Enterprise Investment Fund (SEIF) which an NHS trust is unable to do.

What is a not for profit company and how might it work?

The company is owned by staff who could be the shareholders. It is possible that it would be structured as a
company limited by shares of a nominal value, for example £1 each. The shares would be owned by staff and would not be available for resale. This means that staff could be the true owners of the business but without any personal financial risk. 

Shares could not be transferred and this would mean the business could not be bought by a third party. Any money saved or made by doing things better, differently, or by marketing developing services and products, could be re-invested for the benefit of patients and staff. If the company made a loss, it would need to look for greater efficiencies, just as an NHS trust would have to.

An alternative to a social enterprise

• PCT provider unit (current arrangement) 

This would be an arms length trading organisation (ALTO) within the PCT, led by a provider board and accountable to the PCT. This is essentially the structure which has been in place since April 2008. This is unlikely to remain an option given the long standing national policy to separate the commissioning and provider functions of PCTs. How long we could stay as an arms length trading organisation is unclear. There has been a public verbal statement from the Department of Health that ALTO will not be acceptable after April 2010, but this has not yet been enshrined in policy or guidance – the PCT Board are clear that this is not a long term option for WECHS.

• Community foundation trust (CFT)

CFTs are independent organisations accountable to Monitor, an independent regulator, and not the Department of Health. They are legal entities in their own right – the PCT Board consider this not a viable option as WECHS is considered too small an organisation to become a CFT in its own right and would have to consider joining with another provider arm to pursue this option. This would not necessarily encourage the focus on local communities or integration with primary care which is at the heart of commissioning intentions. In any case there is little chance of many more community foundation trusts being established and the infrastructure costs of a new trust may in any case be unaffordable given the recession.

• Horizontal integration with other community care services

Integration of care services provided by the PCT with other community care services provided to the same population by other government agencies, and in particular by the local authority. This is not an option the PCT Board currently believes serves the needs of their commissioning plans. Currently many local authorities are transferring their directly provided services to the private or third sector. But not in partnerships with local GPs

• Vertical integration with an acute trust 

Integrate the PCT’s community services with acute care provided by Princess Alexandra NHS Trust or a neighbouring acute foundation trust – the aim of the commissioning plan is to transfer services from acute care to community and primary care settings not to increase the size of portfolio of acute services.

• Horizontal integration with a non acute trust for example mental health 

While these trusts often have a strong community focus which might be beneficial they also cover large geographical areas and are usually very specialised in what they do. This might detract fromlocally sensitive services.

• Managed dispersal

Through the procurement plan, services are gradually transferred to the organisations successfully awarded a contract. It is likely though that WECHS will need a temporary host while this happens as NHS West Essex are clear that they will not remain the hosting organisation.

• Integration with primary care forming a social enterprise model

Community services would be integrated with primary care services within west Essex. Staff and potentially GPs establish an organisation themselves which provides community services. This may be registered as a social enterprise, a not for profit organisation, working for the public benefit, that can re-invest any surplus in services – this is the PCT Board’s preferred option at this time and on which staff are now being consulted through this consultation paper.

• An integrated organisational model led by local GPs

This would be a company which would have a contract with the PCT. Apart from the social enterprise model described above, this is the only model that would secure the same benefits for patients of a locally focussed integrated service provider. For this reason, this is the PCT’s present preferred alternative option if staff do not want to establish a social enterprise.

Big Changes For Staff And Patients At Saffron Walden Community Hospital

Saffron Walden Reporter | 23 October 2009

A SHAKEUP in the way health services in the region are run could mean big changes for staff and patients at Saffron Walden Community Hospital.

Some of the services currently delivered by NHS West Essex – the primary care trust (PCT) which covers Uttlesford – could become part of a new independent organisation.

If the plan gets the go-ahead it would mean that the hospital, as well as many other services such as district nursing and health clinics, will become a separate not-for-profit company known as a social enterprise.

Branch chairman of Unison (the union for public sector workers), Terry Ward, believes the proposals could give a raw deal to employees and service users.

“If this split happens then it’s possible that the PCT will buy cheaper services from elsewhere, rather than the facility at Saffron Walden, which makes a mockery of the idea of a community hospital,” he said.

“And staff, who have worked for the NHS for a long time and want to continue to work for the service which they are very proud of, are now being asked to privatise themselves.”

“A lot of resources are being used to push the social enterprise model and we want to make sure that employees are fully aware what they are voting for.”

There are a number of alternatives to privatisation and staff will be given a vote on December 9, after a 90-day consultation, on whether to adopt the idea.

The vote concerns the future of the provider arm of the PCT, known as NHS West Essex Community Health Services, which has an annual income of £34 million and employs nearly 1000 people.

It provides health services in community hospitals, clinics, health centres, GP surgeries, children’s centres, schools and other locations across Uttlesford, Harlow and Epping Forest.

Managing director Vince McCabe said: “What ever happens, local people will continue to receive all their NHS services as they have before, free at the point of delivery, paid for out of the public purse and commissioned by NHS West Essex.”

He added that the social enterprise model would be the best way to “protect and develop” services for the future.

“It would give our frontline staff greater freedom to make decisions closer to patients,” he said. “They would also have a bigger say in how things are run.

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Integrated Care Network – An Introductory Guide

Posted on October 26, 2009. Filed under: Integrated care, Reports/papers | Tags: , |

Department of Health | accessed 26 October 2009 (pdf)

The programme of Integrated Care Pilots (ICP) is a two-year Department of Health (DH) initiative. Its purpose is to explore different ways of providing health and social care services to

help drive improvements in local health and wellbeing.

The programme of Integrated Care Pilots (ICP) is a two-year Department of Health (DH) initiative. Its purpose is to explore different ways of providing health and social care services to help drive improvements in local health and wellbeing.

Integrated care is an important building block within the strategic plan for improving the health and wellbeing of the population of England, as highlighted in both the NHS Next Stage Review report High Quality Care for All and the concordat Putting People First. Both documents stress the importance of improving local health and care services by offering personalised, flexible and high quality services, where the individual is at the centre and engaged in service organisation. Integration may refer to partnerships, systems and models as well as organisations; crossing boundaries between primary, community, secondary and social care.

Each of the 16 pilot sites participating in the national programme has developed an integrated model of care to help respond to particular local needs. Using their in-depth knowledge of the local population, the pilots are designing services that should be flexible, personalised and seamless.

The ICP programme is one of a number of initiatives looking to deliver these objectives. All pilots will be working with local organisations involved in world class commissioning (WCC) assurance Year 2, and participation in ICP should enable sites to demonstrate success against many of the competencies for WCC assurance.

The following pages provide summaries of the work each pilot will be doing over the next two years as they explore the potential and impact of their models, whilst identifying learning and best practice to be shared with others.

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Walk-in doctors’ surgery launched in Nuneaton

Posted on October 20, 2009. Filed under: GP-led health centres, Integrated care, Journals, Press/News Releases, Providers | Tags: , |

Coventry Telegraph | 20 October 2009

AN INNOVATIVE walk-in doctor’s surgery has been launched at a health centre in Nuneaton.

It will allow patients to have an appointment even if they are registered with another surgery and is part of a government programme to increase access to family GP services.

George Eliot Hospital has become the first Acute NHS Trust in the country to run a GP-led facility, which is based at Camp Hill Health Centre, and is supported by NHS Warwickshire.

Health Minister and North Warwickshire MP Mike O’Brien, who performed the opening, said: “This will make a huge difference in improving access to health care for local people.

“Centres like this one are opening up and down the country, complementing services provided by existing practices.

“The centres are proving popular with patients who have told us that they want to be able to see a GP at times convenient to them.

“This centre will offer patients the greater choice and flexibility they want, being able to see a doctor or nurse between 8am and 8pm seven days a week, while still remaining registered with their family GP if they so wish.”

As well as increasing access to GP services, the Ramsden Avenue centre will also have a strong focus on promoting better health and ensuring everyone has access to the services and care they need, particularly for hard-to-reach groups.

Some of the health checks and treatments on offer will include physiotherapy, minor surgery and family planning.

Paul Jennings, chief executive of NHS Warwickshire, said: “We know that those living in the north of the county are statistically more likely to suffer ill-health and we are focused on tackling these health inequalities.

“Camp Hill Health Centre is the result of effective partnership working between NHS Warwickshire, the local community and George Eliot Hospital. Its opening is sure to have a positive effect on health services in the area.”

Sharon Beamish, chief executive of George Eliot Hospital, said: “As a well known local NHS health care provider we are delighted to have been given the opportunity to provide primary care to the community.

“We are looking forward to working with local people to develop services that they want and need in the area and we are fully committed to providing the best care possible to all who choose to use the services in Camp Hill.”

Opening of new GP-led health centre with Warwick Medical School

Warwick Medical School | News Release | accessed 1 October 2009

A new GP-led health centre in Warwickshire developed in conjunction with Warwick Medical School has officially opened its doors for the first time. 

The Camp Hill Centre, based in Nuneaton, has been opened by the Minister of State for Health Services Mike O’Brien MP.  

The Camp Hill area was chosen to benefit from a new health centre as part of the Department of Health’s alternative providers medical services (APMS) contracts. These contracts enable PCTs to deliver health services tailored to local needs. 

Warwick Medical School has contributed towards the development of the health centre and created a learning environment for both its undergraduate and postgraduate students. The health centre will become a teaching hub, providing local leadership to teaching practices.    

Hospital trust opens GP centre

Health Services Journal | 20 April, 2009 | Updated: 23 April, 2009 0:00 am | By Sally Gainsbury

A hospital trust in Warwickshire has become the first to take over the running of a GP-led health centre.

George Eliot Hospital trust plans to open the new 8am to 8pm health centre this October.

The development will be watched carefully as there have been concerns that hospitals should not be allowed to “vertically integrate” with GP services lest they be tempted to use them to create additional demand for acute care.

DH approval

The Department of Health’s guidance on the issue states that any such proposals must be agreed with the department.

But George Eliot trust chief executive Sharon Beamish said the trust “fully supports the drive to provide care closer to home”.

She added: “As an organisation that provides local hospital services we are well placed to extend these services within the community to offer a complete range of healthcare and have a more direct impact on improving the health and wellbeing of [the area].”

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Princess Alexandra opens new health centre in Teddington

Posted on October 17, 2009. Filed under: Integrated care, News stories |

Guardian Richmond | By Chris Wickham | 17 October 2009

A new £4m clinic has been given the royal seal of approval.

Princess Alexandra was at the new Teddington Health and Social Care Centre on Wednesday to open the building after a nine-month construction.

The Queen’s Road centre, which replaces Teddington Clinic, will house community nurses, occupational therapists and care managers, family planning services, children’s psychology and speech therapy, and specialist dentistry services for people with learning disabilities.

The project was funded by the Government, which awarded NHS Richmond the cash to upgrade the clinic. Building work started in December 2008.

Teams from NHS Richmond, Richmond Council and South West London and St George’s Mental Health Trust will be based at the clinic, which is also the new home of the adult community mental health team.

Sian Bates, chairman of NHS Richmond, said: “The centre is an important step in achieving NHS Richmond’s vision for community health services to deliver integrated services, closer to people’s homes.

“The centre is a fantastic addition to local services, providing modern facilities for patients and staff.

“It will enable us to fully support those patients who have long-term conditions in a welcoming environment.”

Councillor Denise Carr, Richmond Council cabinet member for adult services, health and housing, said: “I’m delighted the centre is now open.

“Residents and staff will benefit hugely from the improved facilities.

“It will also be a great chance for our health and social care teams to work together to provide a seamless service for people.”

The princess went on a tour of the new centre during her visit and met some of the staff who will work there.

She also spoke to patients and unveiled a plaque to commemorate her visit.

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Integrated care pilots: An introductory guide

Posted on September 30, 2009. Filed under: Integrated care, Reports/papers |

Department of Health | 30 September 2009

The programme of Integrated Care Pilots (ICP) is a two-year Department of Health (DH) initiative. Its purpose is to explore different ways of providing health and social care services to help drive improvements in local health and wellbeing.

Integrated care is an important building block within the strategic plan for improving the health and wellbeing of the population of England, as highlighted in both the NHS Next Stage Review report High Quality Care for All and the concordat Putting People First. Both documents stress the importance of improving local health and care services by offering personalised, flexible and high quality services, where the individual is at the centre and engaged in service organisation. Integration may refer to partnerships, systems and models as well as organisations; crossing boundaries between primary, community, secondary and social care.
Each of the 16 pilot sites participating in the national programme has developed an integrated model of
care to help respond to particular local needs. Using their in-depth knowledge of the local population, the pilots are

Integrated care is an important building block within the strategic plan for improving the health and wellbeing of the population of England, as highlighted in both the NHS Next Stage Review report High Quality Care for All and the concordat Putting People First. Both documents stress the importance of improving local health and care services by offering personalised, flexible and high quality services, where the individual is at the centre and engaged in service organisation. Integration may refer to partnerships, systems and models as well as organisations; crossing boundaries between primary, community, secondary and social care.

Each of the 16 pilot sites participating in the national programme has developed an integrated model of care to help respond to particular local needs. Using their in-depth knowledge of the local population, the pilots are designing services that should be flexible, personalised and seamless.

The ICP programme is one of a number of initiatives looking to deliver these objectives. All pilots will be working with local organisations involved in world class commissioning (WCC) assurance Year 2, and participation in ICP should enable sites to demonstrate success against many of the competencies for WCC assurance.

The following pages provide summaries of the work each pilot will be doing over the next two years as they explore the potential and impact of their models, whilst identifying learning and best practice to be shared with others.

Download Integrated care pilots: an introductory guide (PDF, 2456K)

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Integrated care: pride of the community

Posted on August 28, 2009. Filed under: Integrated care, Journals |

Health Service Journal | BY DALONI CARLISLE | 28 August 2009

District nurses embody the high quality workforce envisioned by Darzi, but the sector lacks the commitment to attract new nurses to this 150 year old service, says Daloni Carlisle.

  • District nursing is changing to reflect a modern service.
  • The workforce is ageing and training has been slashed.
  • Renewed commitment to the sector is necessary to deliver the vision laid out in the next stage review.

When Anna Gibbins started as a district enrolled nurse in the early 1980s in Cheltenham, Gloucestershire, she never took her hat off while on duty.

“I was issued with five dresses for summer, five for winter, a cardigan, a blazer, a wool coat and a pillbox hat that I wore at all times,” she recalls. “The Queen’s Nurse in charge told me ‘a district nurse never takes her hat off’, so I didn’t.”

This was just 25 years ago, in the days before the central sterile supply department took away soiled dressings – so they went into the grate. “Every house had an open fire,” says Ms Gibbins.

And district nurses were thrifty, re-using everything and fashioning items from what was to hand – turning eiderdowns into pressure relieving cushions, for example.

That world is hardly recognisable now and seems to have more in common with 150 years ago, when district nursing was founded (see box), than with 2009. In their anniversary year, district nurses are reminded of their past, but also looking to the future to find their place in the post-Darzi health policy landscape.

The home front

District nurses are defined by their place of work: people’s homes. With health policy aiming to provide care closer to home – whether managing long term conditions, preventing unnecessary emergency admissions or delivering end of life care – who better to help develop such services than a corps of district nurses?

That, at least, is the argument put forward by the Royal College of Nursing and Queen’s Nursing Institute, the charity that supports community, or district, nurses. The institute’s report 2020 Vision: focusing on the future of district nursing, published in January, stated: “The principles… that have lasted 150 years still fit the bill today. In today’s terminology, they are known as ‘better care, closer to home’, ‘patient choice’, ‘integrated care’ and ‘co-production’.”

“We know there are a number of people in hospital who do not wish to be there, in addition to the people who are admitted but did not need to be,” says RCN primary healthcare adviser Lynn Young. “The public say they want to die at home and that is pure district nursing. We can provide such care to fabulously high standards.”

Institute director Rosemary Cook says district nurses have the skills to deliver on the new agenda.

“There is a bigger difference between nursing in the home and in clinical settings than between primary and secondary care nursing. Nurses are unsupervised, which has implications for quality of care and their own safety. They have learnt to apply principles such as asepsis [techniques to reduce infection] in an environment where every single case is different,” she says.

Clinically, they have come a long way too.

“District nurses’ work has changed significantly because of the push to discharge patients earlier,” says Sally Bonynge, executive director for long term conditions at Central Surrey Health, a social enterprise led by nurses and associated health professionals.

“We are now taking some complex cases that would historically never have been able to come out of hospital,” says Ms Bonynge. “Yet with different ways of working, partnerships and extended roles there is always a way to do it.”

But do commissioners recognise this?

“It is somewhat taken for granted,” says Ms Cook. “[Primary care organisations] have had district nursing services for a long time and let them get on with it. They know what they do in the home is different but there has been no real scrutiny of the different elements that make up the kind of care they deliver.”

However, there are examples of organisations that have used district nurses’ skills to their full. Examples are in telehealth or in virtual wards, both of which are initiatives designed to help people stay at home and prevent emergency admissions.

Central Surrey Health is a learning centre for the NHS Institute’s productive community initiative.

“We are focusing on the district nursing team and changing current working practices,” says Ms Bonynge. “This could be even more exciting than the productive ward [the model on which the initiative is based], as it is so complex. There is only so much you can do to control the patient’s home environment.”

But all is not well in the sector. Both the QNI and RCN have charted rising case loads and falling numbers of qualified district nurses over recent years.

“There is a whole range of issues facing our members. The national trend has been to employ more healthcare assistants to do the work of district nurses. We are not against healthcare assistants, but you have to get the balance right and we are concerned that there has been a dilution of workforce that will get worse as the elderly population grows and more people need these services,” says RCN director Peter Carter.

The RCN says bald workforce figures showing a rise in the number of community nurses from 50,481 in 2000 to almost 62,000 in 2007 disguise a drop in district nurses, whose roles have been replaced with staff nurses and healthcare assistants. There are now around 10,800 district nurses employed in the NHS.

“If you align the workforce with the government’s push towards care closer to home we estimate that we have actually got about half the number of district nurses needed to do it properly,” says Mr Carter.

The workforce is ageing too. In 2007, 58 per cent of district nurses were over the age of 45 and 17 per cent over 55. Training has also been slashed, says Ms Young, so closing this gap will require long term commitment and investment in creating new training opportunities and attracting young nurses to them.

The QNI is also concerned. The 2020 report says: “District nursing services are currently being diluted by loose use of the title, wide variations in pay banding and career structure, reduction in leadership opportunities and lack of recognition of the value of their specialist education.”

Friends in high places

The role has some friends in high places, however. Health minister Anne Keen is a former district nurse and general secretary of the Community and District Nursing Association. Like any district nurse she is ready to regale you with tales of her time in the community.

“There was the time I got bitten on the leg by a goose,” she recalls with evident glee. “I was nursing a pig farmer but he refused to come out of the pig pen so I had to go to him, get him to drop his trousers, give an injection and then run across the fields chased by geese. I don’t think there are many health ministers who could say they have had that kind of experience.”

In 25 years of nursing, her time as a district nursing sister was her favourite, says Ms Keen.

“Your community is proud of you. You go through the front door and you are in a patient’s home. You have to be a confident practitioner and very knowledgeable.”

She is well aware of concerns about the role’s erosion – and of the potential for the role to develop in the near future.

“The high quality workforce of Lord Darzi’s next stage review is made for the role. We cannot afford to lose district nurses and we need to look after them.”

But skill mix will have to change, with district nurses delegating their skills and knowledge to others, she adds.

Ms Keen also agrees with Ms Cook about commissioners’ views of district nursing.

“We must spell out the value of district nursing to them more clearly. Nurses have not been very good at that in the past and it has been easy for people to dismiss them.”

Welsh chief nursing officer Rosemary Kennedy started as a district nurse in rural North Wales in 1973, caring for a village community and outlying farmsteads.

“We were very much part of the community, seen as ‘theirs’ and almost on a level with the school master or minister. It was a really wonderful feeling of belonging and knowing the people you cared for.”

The NHS in Wales also wants to move care closer to home and Ms Kennedy says she has brought a “huge amount” from her days in the district to her current role. She knows from experience the intensity of nursing that is possible at home, having cared for patients with acute coronary conditions.

“It was a question then of the balance between moving them 52 miles or caring for them at home.”

Ms Kennedy identifies capacity as the main challenge. Some of this will be addressed through skill mix changes, but getting the right levels of specialists will take time. A consultation on the future of community nursing in Wales is due to close in May. It will also consult on a new career ladder that would offer modular education, allowing nurses who want to test out the specialism the chance to do it step by step without having to make the jump in to a full time role or education.

“The crucial thing is that one size does not fit all,” says Ms Kennedy. “Our starting point is this: what is the community? What are their needs and how do we

meet them? In some cases they will be heavily weighted towards specialist nurses delivering intensive and holistic care. In others it will be different.”

Overall, there is a good deal of optimism about the future of district nursing. There are some dinosaurs around but there are many more innovators, says Ms Cook. There are areas where district nursing skills are being diluted and lost but some primary care trusts are investing in them, adds Mr Carter.

In England, there is the prime minister’s commission on the future of nursing and midwifery to look forward to, as well as the primary and community care strategy now being developed, which is chaired by Department of Health director general for commissioning and system management Mark Britnell.

“It is a time for optimism,” says Mr Carter. “We have a great deal of faith in Mark Britnell. If his ideas are properly supported it could transform community services.”

The history of district nursing

District nursing as an organised movement began when the Victorian Liverpool merchant and philanthropist William Rathbone employed Mary Robinson to nurse his wife at home during her final illness. Following his wife’s death in May 1859, he wrote: “It occurred to me to engage Mrs Robinson to go into one of the poorest districts of Liverpool and try, in nursing the poor, to relieve suffering and to teach them the rules of health and comfort.”

Three months later “she came back saying the amount of misery she could relieve was so satisfactory that nothing would induce her to go back to private nursing, if I were willing to continue the work”.

Florence Nightingale advised Mr Rathbone to start a training school attached to the Royal Infirmary in Liverpool. Built by May 1863, district nursing associations soon spread to other cities, including Manchester, Leicester and London.

The Queen’s Nursing Institute was founded in 1887 with a grant from Queen Victoria’s Women’s Jubilee Fund. Queen’s Nurses later joined the war efforts of both world wars before joining the NHS in 1948. Although training ceased in 1968, the title Queen’s Nurse was again awarded in 2007 to those who passed a rigorous assessment.

For more information

A changing role

Candy Pellett qualified as a district nurse in 1999 and is now a district nurse case manager for Lincolnshire primary care trust.

“My role is with people with long term conditions and palliative care needs. That means I spend longer with patients with more complex needs and delivering a complex package of care. We now do work that was previously only done in hospitals, for example managing Hickman lines [intravenous catheters to deliver medication] or delivering intravenous antibiotics. I have just started undertaking paracentesis [draining fluid from the abdomen] and that is radical.

“This is all very much in line with the Darzi review. I sit on the Department of Health transforming community care review board and think we will see patients being offered more and more complex care in a primary care setting. It is a good time to join the specialism. There are so many different pathways you can follow.”

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Integrated Care Organisation (ICO) project

Posted on August 3, 2009. Filed under: Integrated care, Press/News Releases |

Durham Dales PBC | accessed 3 August 2009

The Darzi Next Stage Review set out a vision for Primary and Community Care.  Buried in the middle of this document was a relatively short piece of guidance which proposed that the Department of Health would pilot Integrated Care Organisations in 2009.

Integrated Care Organisations are an attempt to pilot horizontal and vertical integration of organisations and it very much puts GPs at the centre of those organisations by basing the ICO on a group of practices’ list of patients.

The Department of Health pilots will be designed to see whether or not Integrated Care Organisations can work together to improve patient care. They will also look at how Integrated Care Organisations can be commissioned by their PCTs and which governance models work best for those organisations.

The Department of Health received over 100 worked up bids, 37 of which reached the final stage of the selection process.

In the North East, we had seven ICO bids in the final 37, from the Church View Medical Practice, Newcastle Hospitals NHS Foundation Trust, Northern Doctors Urgent Care Centre, Northumbria Healthcare NHS Foundation Trust looking at COPD, Northumbria Healthcare NHS Foundation Trust looking at the Complex Elderly, Stockton on Tees Teaching PCT and the only bid from County Durham and Darlington being the Durham Dales Cluster ICO bid.

The Durham Dales ICO is attempting to bring together all the general practices in the Durham Dales Cluster, Durham County Council (Social Services Provider), County Durham & Darlington Foundation Trust (Secondary Care Provider), Tees, Esk & Wear Valley (Mental Health Trust Provider), County Durham and Darlington Community Health Services hosted by NHS Darlington and North East Ambulance Services. All of those organisations are signed up to work together as part of this bid.

The outcomes we expect to deliver through this pilot will be as follows:

  1. prevention of disease
  2. reduced emergency admissions and A&E attendances
  3. improved access for patients
  4. reduction in health inequalities
  5. greater patient involvement
  6. more cost-effective services

The process was rigorous and we had to answer a number of clarification questions around the bid for the Department of Health. This was followed by a visit from the Department of Health on 3rd March and we had very strong public and clinician involvement at that meeting.

We have set up a number of workstreams to deliver each of the areas highlighted above. The Department of Health will require us to deliver a rigorous process of monitoring and the development of metrics to show what we have delivered and to show improvements in patient care.

This pilor should allow local clinicians to be very much more involved in the development of services in the Durham Dales Locality and the development of services in Bishop Auckland General Hospital. 

Durham Dales ICO Bid Document

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Integrated Care Organisations

Posted on August 3, 2009. Filed under: Integrated care, Press/News Releases, Providers | Tags: |

Assura | Cambridgeshire PCT | accessed on 3 August 2009

Assura is working with groups of GPs across the country to develop new models of healthcare provision and organisation by working in partnership with other NHS bodies, such as local hospitals and PCT community services. The name for these partnerships is Integrated Care Organisations (ICOs).

Cambridgeshire ICO

In Cambridgeshire, Assura Cambridge has formed an ICO with Cambridge University Hospitals NHS Foundation Trust and Cambridgeshire Community Services to improve end of life care for over 170,000 patients.

The Cambridgeshire ICO proposal was one of only 16 projects across the country that were appointed by the Department of Health as ICO pilots and will aim to support more patients in their own homes and to shift resources from the hospital budgets to fund additional primary and community services.

Over the next two years, the three organisations will work together to identify the particular needs of dying patients in the community and find ways for different services and organisations to work together to enable people to be cared for and die in the place they choose.

The Department of Health will help the ICO pilot by giving the partnership funding to take part in the programme and by providing support when problems that need fixing are identified.

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Integrated care pilot for Chronic Obstructive Pulmonary Disorder (COPD) in North Tyneside

Posted on July 17, 2009. Filed under: Integrated care, Press/News Releases |

NHS North of Tyne | News | 17 July 2009

Doctors in North Tyneside are preparing to test a new way of working with patients who have chronic obstructive pulmonary disease (COPD) as part of a national project.

The 15 GP practices in North Tyneside are trialling a new approach which is developing ways of joining up the care patients receive in hospitals and the community to improve their experience and enable them to stay as well as possible.

Social and health care services in North Tyneside have chosen to support developments in COPD as this is a very common problem with high numbers of local people with the condition, many of whose lives are greatly affected.

The project is a joint venture between local practices in North Tyneside, the British Lung Foundation, North Tyneside Primary Care Trust (PCT), NHS Newcastle and North Tyneside Community Health, commissioners at NHS North of Tyne, Northumbria Healthcare NHS Foundation Trust, North Tyneside Local Authority and out-of-hours GP care providers Northern Doctors Urgent Care.

Local GP Dr Caroline Sprake, lead for the project, said: “I am very excited about what this new pilot can deliver. We think this approach can ensure much more joined-up services for patients living with COPD, who as a result will be able to feel much more in control of their own health.”

Participating practices will be inviting individual patients with moderately severe COPD to take part. Each patient will be given a named ‘key worker’, a practice or district nurse, who will work with them to develop a personal care plan. This will include information and support to help them understand how COPD affects their own and their families’ lives, what can be done to help, and in particular how to best manage their own health care, including any flare-ups.

Patients will carry copies of their COPD records so that they can share them with other health professionals across a range of services who may need to know their history. It is different from the care that patients currently receive as each patient will have a named key worker who will be able to support each patient planning a programme which is individually tailored to their needs. The key worker will also contact patients regularly to see how their plan is working.

The pilot will continue for approximately two years and information gathered will be used both locally and by the Department of Health to compare patients’ experiences. We will also be interested in whether the project has streamlined the patient pathway and reduced the number of times patients use services including A&E, GP out-of-hours and hospitals to see if the approach is a better way of providing local health services.


Photo caption: Dr Caroline Sprake

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Concerns over GP surgery hospital buy-out

Posted on July 14, 2009. Filed under: Integrated care, News stories | Tags: |

OnMedica | 14 July 2009

The NHS Alliance has today criticised a pilot scheme which will see a GP surgery merge with and be directly employed by an NHS Foundation Trust. Darzi report.jpg

The Alliance says the integrated care scheme proposed by the City Hospitals Sunderland FT “is against the interests of both patients and taxpayers”.

At a time when there is greater competition between hospitals actively seeking the “business” provided by primary care commissioners, the Alliance says the merger is financially motivated.

“In fact, the perception could be that the interests of the Foundation Trust lie more in ‘capturing the supply chain’ than in achieving integration”, it added.

Integrated care is one of the key planks of health minister Lord Ara Darzi’s NHS reforms and is designed so that patients get more seamless health, community and social care.

The Alliance says it supports the concept and championed the idea of closer links with hospitals, community and local authority services, but feels that such collaborations should be about integrated care delivery rather than integrated organisations.

Under the scheme the Church View Medical Practice in Sunderland will merge and be directly employed by the Foundation Trust.

NHS Alliance chief executive Michael Sobanja, said: “An integrated organisation will not necessarily achieve the delivery of integrated care. There is some anecdotal evidence to support this in Northern Ireland where health and social care services have been the responsibility of a single organisation for over 10 years.”

Mr Sobanja said there are also concerns around independence, adding that this merge would compromise the practice’s ability to meaningfully engage in practice-based commissioning. By merging into one entity, the Trust would become, in effect, employer of the medical practice staff, including all practice-based clinical staff.

The Alliance says this could potentially impact on the GP’s role at least three levels: as an independent advocate for patients; as a gatekeeper for other NHS services, particularly hospital services; and as a key player in practice-based commissioning.

Mr Sobanja added: “How can an employee of a large organisation be guaranteed to offer independent advice when the vested interest of the hospital may be at stake? This may affect the best interests of patients and restrict choice.”

Mr Sobanja’s comments come in a response to the Co-operation and Competition Panel for NHS Funded Services consultation on the merger. The Panel should make its decision by next month. The trust said that there was nobody available to comment on the Alliance’s concerns.

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Integrated care pilot to be investigated

Posted on June 17, 2009. Filed under: Integrated care, Journals | Tags: , |

Health Service Journal | By Sally Gainsbury | 16 June 2009

One of the Department of Health’s integrated care pilot schemes is to be investigated by the co-operation and competition panel to see if it breaches merger, choice and competition rules.

Under pilot scheme, City Hospitals Sunderland foundation trust plans to merge with a local GP practice. The merger would represent a case of “vertical integration”, which the DH has been wary of due to concerns acute trusts could use control of a GP practice to drive up the number of acute referrals.

DH competition rules, published in 2007, state that primary care trusts must seek permission from the department before contracting for “list-based primary care services” through a hospital provider.

The panel’s investigation will use the Sunderland case to test assumptions and concerns about vertical integration. In a statement, the panel said it would “assess the extent to which the integrated care scheme may limit patient choice in relation to the type of NHS-funded healthcare services provided by each [provider]”.

It will also assess any benefits the model brings patients and taxpayers.

The panel is inviting submissions from interested parties. The closing date is 26 June. The earliest date for the completion of the investigation is early August, with the possibility of it continuing until the end of November if the issues are deemed complex.

More on integrated care

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Integrated care heightens provider monopolies risk

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Integrated care

Posted on June 10, 2009. Filed under: Integrated care, Journals |

British Medical Journal | Feature: Health Policy | Nigel Hawkes, freelance journalist | Published 8 May 2009

The government hopes that integration of services will improve care, but as Nigel Hawkes reports the pilot schemes have a lot to prove

Sixteen organisations have been chosen to pilot new models of integrated care in the English National Health Service. The scheme, announced in the Darzi review last July, aims to improve services for defined groups of patients by integrating health and social care, or primary and secondary care, or both.

The pilots announced on 1 April include seven that will focus on long term conditions or chronic diseases, three on elderly people and end of life care, two on dementia, and one each on falls, mental health, delivery of rural health care, and substance misuse. Geographically the pilots are unevenly spread, with four in the North East Strategic Health Authority, four in the South West, but none in South Central, South East Coast, or West Midlands (box). The 16 were chosen from 100 applications. 

Integration has long been an article of faith among NHS commentators, and the new Care Quality Commission expresses that faith by combining the regulation of health and social care in a single organisation. But previous efforts to achieve integration have a mixed record. Since 2000 it has been possible to achieve integration through creating care trusts, but only 10 have been set up. UnitedHealth’s Evercare scheme, which sought to achieve seamless care through better case management, was piloted in nine primary care trusts (PCTs) in 2003-4 and achieved some improvements but no significant effect on admissions, bed days, or mortality.

This uncertain background explains why integrated care is being piloted, rather than launched nationally. The pilots will run for two years before being evaluated for a further three years. They will, says the Department of Health, “allow communities to take a fresh look at how to deliver health and social care, based solely around the needs of the local population.” The successful bidders have been urged “to look beyond traditional boundaries (such as between primary and secondary care) to explore whether new, integrated models can improve health and social care services.”

Rebecca Rosen of the Nuffield Trust, a general practitioner and an expert on integrated care, says that the challenge will be to show that the extra costs of integrated care are outweighed by savings from fewer hospital admissions. “The evidence base is not very strong,” she admits. “There is very little robust evidence that integrated care can reduce admissions.”

She says that the pilots cover a diverse range and will be evaluated by experienced researchers. “They will be looking for two things,” she says, “better experience of care for the patients and greater cost effectiveness.

“Integrated care isn’t new—there are papers in the literature going right back to the 1970s. Generally, patients appreciate it and rate their care as better, but the cost can go up because of better medication. Both prescribing and compliance increase overall, so spending increases.”

Some pilots have a head start. Torbay is already a care trust and will be piloting integrated care for elderly people across primary, secondary, social care, and mental health services. Chris Ham, professor of health policy and management at the University of Birmingham, writes in a recent report for the Nuffield Trust that Torbay has achieved some improvements in care, including quicker assessment and delivery of intermediate care and an improved rating from the Commission for Social Care Inspection, the predecessor of the Care Quality Commission.

Will integration work?

Integration means different things to different people. In the past, it has often consisted of ramming together organisations with different histories and cultures and expecting economies of scale and improved services to follow. “New and better types of care cannot be delivered by housing different professionals under one roof or merging multiple organisations,” said Niall Dickson, chief executive of the King’s Fund.

“It requires bringing teams together, integrating the way staff work, and creating new relationships between organisations. It is also important that we do not create new monopoly organisations around the NHS which deny patients choice—we need services that are responsive and understand that either patients or commissioners may decide to go elsewhere.”

US experience also suggests that integration is easier in organisations that are both commissioners and providers of care. PCTs are now under strong pressure to get out of provision altogether, which could work against integration, warns Minoo Irani, a consultant paediatrician who represents the interests of consultants working in primary care in the NHS Alliance. Without clarity about the basics, he says, that integrated care pilots risk perpetuating fragmented health care, while still appearing integrated. “Confused enthusiasm is never a good thing on which to base health policy,” he warns.

The Audit Commission has also expressed doubts about partnership working in the public sector, warning that it can generate confusion and weaken accountability. “Local public bodies should be much more constructively critical about this form of working,” it said in 2005. “It may not be the best solution in every case. They need to be clear about what they are trying to achieve and how they will achieve it by working in partnership.”

The only London project to make the cut believes it has met these criteria. Tower Hamlets in East London, one of the poorest parts of the capital, is aiming to improve the health and wellbeing of patients with long term conditions, delay the progress of disease, and increase the uptake of services by hard to reach groups.

Anwara Ali, lead member for health and wellbeing at Tower Hamlets Council, says: “It’s all about putting local people’s needs to the forefront of everything we do and structuring how we work around that. In Tower Hamlets we have a very strong partnership in place with our health colleagues which will support us in this work.” Alwen Williams, chief executive of NHS Tower Hamlets, says it is one of the trust’s major priorities to improve care for people with conditions such as stroke, diabetes, and cardiovascular disease.

The evidence for integration, as summarised by the Department of Health, does not inspire huge confidence. It can be a successful way of breaking down barriers between primary and secondary care (vertical integration) and between health and social care (horizontal integration). But the evidence of vertical integration on costs, outcomes, and patient experience remains weak.

Context is important, the department’s summary says. Supportive leadership, strong local partnerships, and effective information technology and administrative systems are vital. It concludes on a gloomy note: “Integration has seldom increased efficiency. This is due to such factors as significantly different practices existent in the organisations that are to be integrated; and the steep learning curve inherent in joining with another organisation. Longstanding power imbalances between acute and community care makes such integration a challenge.”

Dr Rosen believes there are several elements that need to be right to make the integrated care pilots work. “They have to be smart about the way they use data. If you are going to achieve real integration, the challenge is to use available data to the full, and you have to invest effort and resources to achieve that. In successful US systems, a lot of what is achieved is down to the clinical information systems, providing prompts or protocols on screen, for example, or risk stratifying patients.

“Second, you need high quality clinical leadership and governance arrangements that make it clear what you are aiming to achieve. The challenge of good integrated care is to ensure that patients don’t fall between the cracks. You need to build a shared understanding and invest a lot in team development.

“Finally, my other big question is whether financial incentives can be aligned to make it work. There are other NHS policies, such as patient choice, that can disrupt it.”

If the pilots fail, at least the time and money wasted will be limited—assuming the department heeds Niall Dickson’s warning not to roll them out before lessons have been learnt, as has happened in the past. If they succeed, they could transform the way health care is delivered, according to enthusiasts such as Peter Reader, medical director of Islington PCT. But past experience teaches caution. Many NHS reforms, heralded as revolutionary when launched, have gone out of fashion and been abandoned before they have had time to show either success or failure.

Cite this as: BMJ 2009;338:b1484

Competing interests: None declared.

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Practice win integrated health awards from Prince Charles

Posted on May 21, 2009. Filed under: Integrated care, News stories | Tags: , |

Healthcare Republic | 20-May-09

Winners of the new NHS category of Prince Charles’s Integrated Health Awards have received presentations from the royal.

The winner of the GP practice category was Patford House Surgery in Calne, Wiltshire, which devised an imaginative project to tackle childhood obesity through local primary schools.

It invited 200 Year 4 children to a Fun Fitness session in January and found that nearly one in four fell outside weight guidelines. This was followed by a 12-week programme. Parents take part in healthy eating sessions, there is even a Michelin-starred chef to advise on tasty dishes, while the children are simultaneously involved in fun physical activities.

The best practice-based commissioning group was STAHCOM, based in St Albans, Hertforshire, which provides a high-volume acupuncture service for osteoarthritis of the knee. Treating four at a time, most patients are 50-80 years old, some previously relying on physiotherapy and lifestyle advice but others facing knee surgery.

Only four out of 42 patients taking part needed to be re-referred for further treatment.

Dr Michael Dixon, The Prince’s Foundation for Integrated Health’s medical director, said: ‘Both these projects are wonderful examples of what integrated health really means – not just treating people when they are sick, but helping them keep as healthy as possible.’

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Integrated care organisations and their vital PBC role

Posted on April 29, 2009. Filed under: Integrated care, News stories |

Pulse | Practical Commissioning | Interview by Miranda Griffin  | 29 April 2009

integrated_care_circle_of_people___alamy___single_use_onlyThe announcement this month of the final 16 integrated care pilots has put ICOs in the limelight – but ICOs are about more than the pilots, as Dr Oliver Bernath explains.

1. Define an ICO for me
Well, the first thing to stress is that being an integrated care pilot does not mean you are actually an integrated care organisation.

The DH integrated care prospectus was very relaxed about the criteria for what could be an integrated care pilot – the pilots had to be based on a registered patient list and have the local PCT’s approval.

The prospectus talked of teams of primary and secondary care clinicians, or health and social care professionals who might be based in the same place or employed by the same organisation and also said integration might possibly involve bringing together resources. Again it was non-specific on the means to pool resources but said this could include delegation to providers of a risk-adjusted capitation sum for a group of registered patients. This would be an integrated care organisation.

Looking at the scope of the newly announced national pilots, I would say they only address narrow slivers of the totality of care – urgent care, elective care, community care, prescribing, primary care. But none of the pilots seems to cover the whole spectrum of care.

2. Do you need integrated care organisations then?
My view is that you need to go for the whole lot – one service, one team, one budget to strengthen the whole patient focus, otherwise we end up with the balloon problem…. squeeze it in one place, only to see the problem pop up elsewhere. We want to have the whole balloon in our hands so that we cannot shift a problem from one area into the other – if we do, inadvertently, we still have to live with the consequences.

So, to me an integrated care organisation is a provider organisation that takes on the PBC budget together with GPs but has a real contractual obligation – the ICO takes on a capitated delegated sum at risk and delivers to the commissioner whatever outcomes and services they want to see. It helps providers to organise themselves without needing to become employees of one company. This way GPs can stay as independent practices.

GPs are the lynchpin of all this as they hold the patient list and have a gatekeeper function for the whole healthcare market.

ICOs have a total pathway view. For example, at the moment a GP knows what care an asthma patient receives in their practice, the hospital knows what care the patient receives with them, but nowhere is it all pulled together and that makes it difficult to see which points of that patient’s care need improvement.

As well as the management capability, ICOs would also provide the analytic capability to map and track entire care pathways with all costs and benefits – both outcomes and patient experience. This can become quite IT-heavy as you need information systems that can enable that analysis not only a year in retrospect but also at the time something like an admission happens.

ICOs would also provide capital, first to buy equipment but also to provide underwriting cover for the overspend risk that is too large for a GP practice to carry.

3. Where has this concept come from?
This type of organisation has not been seen before in the UK, but the need comes from both clinicians and patients.

As a consultant neurologist I felt great frustration receiving referrals where, if I had been involved earlier, I could have prevented half the complications, and when I sent the patient back to the GP I had no further influence. It was an isolated care episode rather than a longitudinal one.

GPs have the same frustrations – it takes a long time to access a consultant’s expertise, the outpatient appointment often takes a long time to come through, then after the consultant has seen the patient the GP gets a letter back that may not address what they felt the problem was. The patient has to navigate the whole healthcare system themselves as they are the only person who sees the whole picture.

The current fragmented system doesn’t really work for patients – when unnecessary complications arise, it is bad for patients and is a drain on healthcare resources.

PBC is a start but it is just the first step of a longer journey. There is not enough transparency around how the budget numbers come together so GPs don’t know how to influence it. Nor do GPs really have the freedom, tools or power to shape it. As

a result it has caused a lot of frustration. ICOs are the next step for PBC, though the need for practices to be like-minded is far greater than geography. The practices involved need to be high-performing and innovative to take this on. There is also scope for the ICO to contain practices from different consortiums and for some practices in the consortium to stay outside the ICO.

4. Why should commissioners be interested when there are so few ICO pilots?
We have started our own pilot outside the national programme with a wide range of initiatives covering the whole range of care. This can be done under the existing PBC

set-up if your PCT is willing. The national pilot programme prepares policy development but it doesn’t stop anyone else from going it alone. We felt we could get more quickly from the pilot stage into the proper ICO stage by going it alone.

5. Why is the patient list so central to ICOs?
If you were to allow a provider to select their patients, they could cherry-pick the young healthy ones and pass those with chronic conditions back to the NHS. The NHS would be stuck with the high-cost population.

Also, if you had specialist providers for different disease categories – for example a specialist organisation for diabetes care – you would be taking apart what primary care is trying to pull together. The commissioner would be paying the GP a fixed amount per registered patient and also paying the specialist provider for diabetes care, so would either be paying twice or would take the money for diabetes care away from the GP.

If the same approach is taken with other conditions you eventually disaggregate the whole primary care package. Then you have no need for a GP and end up in the situation where the patient is looked after by all these specialist providers and nobody looks after the whole patient any more. Also, it would be impossible to allocate a budget if you didn’t have a population base to base it on.

6. What about the provider- commissioner conflict? ICOs seem to blur lines even further.
When a GP sends the patient to a cardiologist are they subcontracting a piece of care or commissioning? This is where the grey zone is but it already exists and is inextricably linked to the job of the GP.

The conflict arises if the GP has a financial interest in influencing patient choice. It may be that the GP’s relationship with the cardiologist is actually good for patient care but the conflict of interest would have to be declared and the profits mitigated.

In my vision, first there has to be full transparency. If the practice has its own cardiologist, it has to tell the patient the appointment might be faster but it has to declare the relationship with the cardiologist.

Second, if provider organisations are not-for-profit community interest corporations where the service gets paid for fairly but there is no additional profit, then the financial interest is just one of providing the best service at the cheapest cost and there is no conflict.

7. Do practice-based commissioners have a choice not to get on the ICO train? What will happen if they don’t?
ICOs will have to prove they are not underspending on patient care to maximise profit and that patients will receive at least as good care, if not better, than they would elsewhere.

GP practices that don’t like being scrutinised are not suited to being part of an ICO. However, I feel most practices that are proactive and proud of what they do will sooner or later join the ICO bandwagon. The practices left behind will probably be the ones that don’t want to engage, or whose GPs are close to retirement or afraid that their standards are not as high as the ICO would demand.

Then the challenge from the PCT’s perspective is to examine how to motivate those practices and what consequences the underperforming practices would have to face. The failings of some practices, which have always been there, will become more obvious.

8. What will happen if we have a change of Government? The Conservatives seem cold on ICOs because of the commissioner/provider split.
Andrew Lansley has said he thinks it is not necessary to create new organisations. In a sense I agree. We do not need something to replace GP practices or hospitals, you do not need a new provider organisation, but you still need a different level of management that understands the total care of the patient across the different providers, and something to help with the systems integration and to make the information flow better, and somebody to take on the financial risks.

Dr Oliver Bernath is managing director of Integrated Health Partners

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Feature: Private practice

Posted on April 22, 2009. Filed under: GP-led health centres, Integrated care, Journals, Providers, Social enterprise | Tags: , |

British Medical Journal | Andrew Cole, freelance journalist | 21 June 2008

1 London |

Contracts to allow general practices to be run by private companies were supposed to be a last resort, but is this really the case? Andrew Cole reports

APMS (Alternative Provider of Medical Services) was once just another of the myriad health service acronyms that English general practitioners (GPs) were expected to master. But in recent months the APMS procurement process has become all too familiar and has led to fears it could threaten the foundations of general practice.

It’s a surprising turnaround. When APMS was launched it was billed as an unexceptional, indeed laudable, attempt to bring new blood into areas where practices had failed or had severe doctor shortages. In those situations contracts would be put out to tender and would be open to all comers—theprivate or voluntary sector or existing NHS practices.

Initially that’s how it worked. But recently the number of APMS schemes has risen sharply while the criteria for choosing this tendering method seem to have widened. The trend gained momentum with the government’s edict late last year that 100 new general practices and 150 polyclinics be procured through APMS.

A survey by the general practitioners’ magazine Pulse in January showed a third of trusts were now tendering for APMS contracts compared with just 10% six months earlier. And when it comes to the procurement process itself, the private sector seems to be winning hands down. Another survey by the same magazine suggests that although around half of shortlisted bids come from NHS practices, only one in 10 is successful, with 91% going to private companies. Private companies are also consistently undercutting practices on price, often by as much as 25%.

St Paul’s Way

One recent example of this phenomenon is St Paul’s Way Medical Centre in the heart of Tower Hamlets, which was put out to APMS tender last year. After an exhaustive procurement process the contract was finally awarded to private providers Atos Healthcare, even though two highly respected local practiceswere also on the shortlist.

The decision sparked angry protests from local health staff and patient groups. It also provoked a vote of no confidence in the trust by the local medical committee and an apparent change of heart by the trust on future tenders. But it also raises the question of whether general practices can ever compete on a level playing field with some of the larger, private organisationsmoving into primary care.

The St Paul’s Way practice is in one of the most socially deprived areas of London. Over two thirds of its 10 500 population is Bangladeshi, and rates of coronary heart disease and mental health problems are almost twice the national average. Consultation rates are also 50% higher than average.

There had been concerns about the practice’s performance for some time so when the husband and wife partners retired in 2006, it was no surprise that the trust stepped in to take over its management.

What was more surprising was that a year later it announced it was putting the practice out to APMS tender rather than working with neighbouring practices to find an internal solution.

“GPs in Tower Hamlets have worked very well with, and have a great deal of respect for, our primary care trust,” says John Robson a GP at nearby Chrisp Street Health Centre. “So it was a double blow to us that having established this good working relationship it then decided to look outside for a solution. In a sense it was a vote of no confidence in local practitioners. One wonders whether there was some external pressure on the trust.”

Dr Robson and his colleagues at Chrisp Street and the adjoining practice at Bromley by Bow decided nevertheless to bid for the APMS contract. They were two of 50 organisations or individuals that initially expressed an interest. This was reduced to a shortlist of five, two of whom withdrew, leaving the final selection between Bromley by Bow, Chrisp Street, and Atos Healthcare.

On the face of it the two local practices looked clear favourites to win the contract. Both have national reputations for innovation and quality. The Bromley by Bow Centre has been a flagship for social enterprise and integrated working and runs several community volunteer projects in the area.

Meanwhile Chrisp Street has established a high reputation for its teaching, innovation in information technology, and progressive clinical care. Two partners work as senior lecturers at St Bart’s and the London Medical School and have led the implementation of clinical care guidelines in East London trusts. They also pioneered web based services across the trust.

Yet in December it was announced the 10 year contract had been won by Atos Healthcare, a subsidiary of the £4bn ({euro}5bn; $8bn) multinational giant Atos Origin. Its health involvement includes providing the information technology for the NHS Choose and Book programme and running two walk-in centres, one at nearby Canary Wharf. But at the time it won the St Paul’s Way contract, it had no experience in general practice. According to its bid, its only clinical acquisitions were the two walk-in centres. Since then it has also successfully bid against local GPs for a new practice at Shinfield in west Berkshire.

Fair competition?

The reasons for its success are revealing. All three shortlisted bidders promised the same extended hours of 8 am-8 pm on weekdays and 8 am-5 pm on Saturdays and had similar scores on most aspects of medical performance. So everything eventually came down to non-clinical issues—in particular, managing a multiuse building, procurement, branding, and price.

That is where Atos came up trumps. Not only was its price 6% lower than the lowest general practice bid, but as a large corporate bidder it had clear inbuilt advantages in marketing and administration.

As far as Dr Robson is concerned, the process shows that the scoring system is “a loaded dice,” heavily weighted against existing small scale practices.

At the same time he feels the scoring seriously underplayed several key features of good medical practice. “We teach 90 medical students a year and put a huge effort into making that happen.” The practice also makes a big contribution to the local economy through its many links with the trust and wider population but also through nurturing a homegrown workforce. But the marking system ignored or gave only nominal weight to these factors.

A large corporation can also afford to write off initial losses in order to get a foothold in the market. He confesses his practice had grave doubts whether the price it quoted in the tender was sustainable. “We went right to the margin if not beyond—but even so Atos undercut us.”

The process was hugely demanding on a small practice’s resources. Chrisp Street spent £12 000 on legal and consultancy fees with one manager and one GP devoting half their time to the bid for three months. In total it spent at least £35 000 on the undertaking.

Joe Hall, a GP at rival bidders Bromley by Bow, agrees the bid was a massive diversion from day to day working. In fact, it was so time consuming he has doubts whether the practice could afford to do it again. “You don’t run general practices with the capacity to do this type of thing.”

Interestingly, another bidder, the south London based Hurley Group, withdrew from the process a week before the final selection partly because of serious doubts about the economics but also because it felt it was not sufficiently local to provide the right support. “The more we examined it, the more we felt itneeded the old-fashioned style of GP who is truly part of the local community,” explains GP Clare Gerada. “If our practice was on their doorstep we would have gone for it. But it needed staff to be attending community meetings, going to local schools, and helping in every way to transform that practice.”

She was shocked when she learnt neither of the local practices had won the contract. “They are two of the best general practices, and it is a shame they will not be able to help a practice crying out for GP leadership and also for the economies of scale a local practice could introduce.”

Tower Hamlets primary care trust insists the final decision on St Paul’s Way was made entirely on merit, with Atos winning “against very high quality proposals from other bidders . . . because of the quality measures they will have in place and the breadth of services they will offer local people.”

However, many local health professionals are unconvinced. Local medical committee secretary Paddy Glackin believes trust managers were taken aback by the final decision, made by an independent selection panel. He also thinks they came under pressure by London region to choose the APMS route in the first place.The local medical committee’s subsequent vote of no confidencereflected real concern that, following the Atos precedent, six other practices under direct trust management would now face an external tendering process and might end up in private hands.

In the event, and under clear pressure from local GPs, the trust has produced a plan whereby five of the practices will be given 12 months to show they can run themselves independently before a final decision on their future is taken. Only if they fail this test will APMS tendering be considered.

Atos Healthcare has now been running St Paul’s Way Medical Centre for nearly five months and claims to have already made several improvements, including extended opening hours, booked appointments, and a walk-in service. It has also refurbished the centre to provide more modern facilities and aims eventually to move into purpose built premises nearby. And it plans to meet regularly with patients to discuss the quality of their service.

Referring to the reasons for its successful bid, Nigel Beverley, director of NHS Services at Atos Healthcare, said it had won because it had shown “it will provide more NHS services to local people and that it is able to provide high quality services.”

The Tower Hamlets experience is being replicated in many other parts of the country. But the government dismisses talk of creeping privatisation of primary care services. According to health minister Ben Bradshaw, even if all the contracts currently being tendered went to private companies—”which they will not”—it would only add up to 3% of the market.

But Dr Glackin is less sanguine. Originally, he says, APMS was designed as a way of supporting inner city areas that were run down or had insufficient doctors. “What’s happened is it has become the only contracting vehicle for any new services that are being offered or provided. So potentially [privateprovision] could expand very rapidly.”

The other problem is that general practices simply do not have the resources or expertise to compete for tenders against large multinational private companies. “It’s just not a level playing field,” says NHS Alliance chairman, Michael Dixon.

“General practices are finding it difficult to put in really professional bids at the moment. And they’re not in a position to loss lead in the way private companies can so their bids will tend to be higher. Asking the average general practice to put in a bid of the sort Atos can put in is like asking a small version of David to fight a much larger version of Goliath.”

Competing interests: None declared.

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Only Connect: Policy Options for integrating health and social care

Posted on April 21, 2009. Filed under: Integrated care, Reports/papers |

The Nuffield Trust Briefing Paper | Chris Ham, University of Birmingham | April 2009


To explore the issues involved in achieving closer integration of health and social care, the Nuffield Trust held a series of seminars led by experts in this field between November 2008 and January 2009.

The series built on previous work by the Trust on integrated care and focused on areas of the country in which primary care trusts (PCTs) and local authorities have experience of working together on issues of common concern. This briefing paper summarises the discussions that took place at the seminars, discusses emerging messages, and identifies the policy implications.

Key points

  •  The flexibilities provided by the Health Act and the option of becoming a care trust have enabled PCTs and local authorities in a number of areas to establish closer integration of health and social care services, and to develop joint approaches to improving the health and wellbeing of their populations.
  •  What works in one area may not work in another, because of variations in context and in relationships between stakeholders.
  •  The journey towards integration needs to start from a focus on service users and from different agencies agreeing what they are trying to achieve, rather than from structures and organisational solutions.
  •  Partnership working depends critically on leadership by elected members and PCT board members, and by senior managers.
  •  Alongside integrated governance arrangements, the development of integrated health and social care teams that are aligned with the work of GP practices serving the same localities has contributed significantly to the progress made in integrating services.
  •  In the areas covered by the case studies presented here PCTs and local authorities are working in partnership, but more work is needed to bring in other partners, particularly those providing acute hospital services.
  •  Future policy on integration needs to be tight on ends and loose on means and the choice of means should be a matter for local decision, taking into account variations in context.
  •  The new Care Quality Commission has a potentially important role in assessing the performance of NHS bodies and local authorities in promoting integration, and in using its leverage to spread the examples of innovation described in this briefing paper to other areas.


The needs of people with learning disabilities or mental health problems and those of older people are rarely either just ‘medical’ or ‘social’. The importance of joint approaches to addressing these needs has been recognised by policy-makers ever since the production in the 1960s of long-term plans for the future of hospitals and what were then called ‘health and welfare services’. The challenge throughout this period has been to turn policy aspirations into practice. This challenge has been acknowledged in High Quality Care for All (Secretary of State for Health, 2008), which announced that a Minister-led review would be established to explore what more needed to be done to promote health and social care integration.

Since the Health Act 1999, moves to achieve closer integration of health and social care in England have focused on the use of three flexibilities introduced under Section 31 of the Act. These are:

  • lead commissioning, under which one authority transfers resources to the other which then leads in the commissioning of both health and social care  
  • integrated provision, under which one authority takes responsibility for the provision of both health and social care
  • pooled budgets, under which authorities transfer resources into a single budget which is managed by one of the authorities on behalf of both.

Alongside these flexibilities, care trusts have been set up in some areas to promote integration. Care trusts were first announced in The NHS Plan in 2000 and powers to create them were included in the Health and Social Care Act 2001. Care trusts combine NHS and local authority responsibilities in areas such as the care of older people and mental health under a single statutory body. They are NHS bodies but include local authority councillors on their boards.

In a review of experience of partnership working in the public sector, the Audit Commission noted:

Working across organisational boundaries brings complexity and ambiguity that can generate confusion and weaken accountability. The principle of accountability for public money applies as much to partnerships as to corporate bodies. The public needs assurance that public money is spent wisely in partnerships and it should be confident that its quality of life will improve as a result of this form of working. Local public bodies should be much more constructively critical about this form of working: it may not be the best solution in every case. They need to be clear about what they are trying to achieve and how they will achieve it by working in partnership. (Audit Commission, 2005, p.2)

It was against this background, of the need for partnership working and yet the difficulties that have arisen in practice, that the seminars took place.

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Integrated care will be tested by only 16 organisations

Posted on April 18, 2009. Filed under: Integrated care, Journals, Providers | Tags: , |

Just 16 organisations have made it onto the Department of Health’s integrated care pilot scheme.

The department had originally said it would select around 20 bids from more than 100 applicants.

Three strategic health authority areas – NHS South Central, NHS South East Coast and NHS West Midlands – have been left without a pilot scheme.

There were 36 organisations on the shortlist published last year, including bids representing all SHA regions.

NHS North East and NHS South West have four pilots each and the East Midlands, East of England and North West regions each secured two.

London and Yorkshire and the Humber have one pilot each.

A DH spokesperson said: “It was always intended there would be around 20 pilots.

“The chosen sites cover a range of diverse models, focusing on innovation and delivering an improvement in outcomes, quality and service user satisfaction.

“The selected sites provide an appropriate range and spread to conduct a robust evaluation.”

Pilot schemes

The schemes range from a primary care trust-led collaboration between GPs, public sector organisations and the third sector to improve dementia care for older people in Bournemouth and Poole to a scheme to help patients with chronic lung disease led by Northumbria Healthcare foundation trust.

Social care, the third sector and local authorities are also represented in pilot schemes.

Clinical areas include older people’s care, long term conditions, dementia, end of life care, cardiovascular disease, mental health and substance misuse.

The pilots were first proposed in Lord Darzi’s primary and community care strategy.

The announcement followed a King’s Fund debate where experts evaluated the lessons the NHS could learn from US healthcare, where integration is more established.

UnitedHealth executive vice president Simon Stevens, a former adviser to Tony Blair, said while it was important to create systems that were integrated through teamwork and infrastructure, no US integrated scheme was a local monopoly.

He said: “If you think about any of the leading integrated systems, there is a third party purchasing system.”

Sites selected by the DH from the shortlist of 36

  • Bournemouth and Poole PCT
  • Cambridge Assura LLP
  • Church View Medical Practice, Sunderland
  • NHS Cumbria
  • Cornwall and Isles of Scilly PCT
  • Durham Dales Integrated Care Organisation
  • Nene Commissioning CIC
  • Newcastle upon Tyne Hospitals foundation trust
  • NHS Norfolk and Norfolk county council
  • Northumbria Healthcare foundation trust
  • North Cornwall Practice-Based Commissioning Group
  • Principia – Partners in Health, Rushcliffe, South Nottinghamshire
  • NHS Tameside and Glossop
  • Torbay Care trust
  • Tower Hamlets PCT
  • Wakefield Integrated Substance Misuse Service

GPs to front integrated care pilot schemes

Pulse | By Nigel Praities | 1 April 2009

GPs will work with care homes, social services, acute trusts and charities to improve patient care under a range of pilot schemes to begin today.

The £4 million scheme involves 16 integrated care organisations in different areas of the country, focusing on health and social care professionals can work together to develop services for patients.

After 100 applications to run the schemes, the winning 16 pilots range from improving the co-ordination of end-of-life care, preventing cardiovascular disease and encouraging more self-care for people with long-term conditions.

The pilots begin today and will run for two years and will be evaluated for their effect on health outcomes, improved quality of care and service user satisfaction.

Health Minister Ben Bradshaw said this was an opportunity for patients to get all the health and social care they need in one place.

‘This programme provides an opportunity for clinicians – working closely with the community more widely – to use their on the ground knowledge to design services that are flexible, personalised and seamless,’ he said.

Integrated Care Pilots – Pilot Summaries

1. Bournemouth and Poole Teaching PCT

This pilot will be exploring a new model for delivering care for older people with dementia, involving collaboration between GPs, public sector organisations and third-sector services. It aims to provide a single point of access to an integrated community team.

2. Cambridge Assura LLP

This pilot will look at how different organisations across the health, social care and third sectors can better communicate and co-ordinate end-of-life care to enable people to be cared for and die in the place they choose. The pilot will also be improving public and patient engagement to ensure services are fully sensitive to user needs.

3. Church View Medical Practice, Sunderland

This pilot will improve quality of care and experience of services for the area’s population of older people. The local acute trust and GP practice will work together as an integrated organisation, and will work in partnership with the PCT provider arm, social services and the patient practice group. The pilot will aim to provide an improved, personalised experience through active management of long-term conditions.

4. NHS Cumbria

This pilot will be exploring a new approach to helping patients with chronic diseases to manage their own care. It will be focusing on increasing the collaboration between GP and patient. It will aim to move care into a community setting and reduce hospital admissions.

5. Durham Dales Integrated Care Organisation

This pilot will involve seven partner organisations working together to meet the needs of a rural population, provide continuity of care and reduce health inequalities. It will explore a number of different care pathways aiming to improve planning information, move care into a community setting, increase patient/carer satisfaction and reduce hospital admissions.

6. Nene Commissioning CIC

This pilot will develop new models of long-term condition management to help patients remain independent for longer and have more choice in their end-of-life care. It will create personalised care plans for high-risk individuals and aim to reduce admissions to hospital.

7. Newcastle Hospitals NHS Foundation Trust

This pilot will provide an improved preventative service for over 60s at risk of falling by broadening the current falls and blackout (syncope) service provision. It will enhance provision and access to care and establish a network of community-centred training services led by clinicians, in partnership with the third sector and other agencies. By developing these community services the pilot aims to reduce the number of falls and admissions to hospital.

8. Cornwall & Isles of Scilly PCT

This pilot will unite primary, secondary, health and social care services by setting up a GP-led memory clinic supported by a team of practice-based case managers and dementia care advisers. It will seek to increase the number of people receiving an early diagnosis, reduce admissions to hospital and care homes and see people maintaining independent living for longer.

9. NHS Norfolk and Norfolk County Council

The focus of this pilot will be on integrating care services for the elderly. Joint working between the PCT and the County Council will identify people in need of support and then work with them to develop personalised care plans. It aims to help elderly people live fulfilling and independent lives and to form care plans that meet the needs of both patients and carers.

10. Northumbria Health Care NHS Foundation Trust

This pilot will be exploring a new approach to helping patients with Chronic Obstructive Pulmonary Disease (COPD) to manage their own care. The pilot will ensure providers work together to co-ordinate care, provide consistent information and education and help patients manage their own care (with assistance from their key worker).The pilot aims to increase patient satisfaction, reduce hospital admissions and reduce the length of stay in hospital when admission is required.

11. North Cornwall Practice-Based Commissioning Group

This pilot involves 10 GP practices in North Cornwall working together to integrate Mental Health community teams, based in a rural location, with a single point of access from GP practices. It will integrate Mental Health acute and social services. The pilot will aim to dissolve boundaries so patients can more easily navigate through the system and ensure they ‘only have to tell their story once’.

12. Principia – Partners in Health, Nottinghamshire

This pilot is designed to help create more informed and empowered COPD patients. It will involve partners working together through two projects to identify ‘at risk’ patients, and work with teams in community wards and with other partners involved in COPD treatment to integrate care along the clinical pathway. It is designed to improve co-ordination of care, increase patient satisfaction and reduce hospital admissions.

13. NHS Tameside & Glossop

This pilot will be seeking to change behaviour amongst people at risk of CardioVascular Disease (CVD). It will involve developing partnerships to identify ‘at risk’ residents, supporting them with diagnosis/treatment but also promoting self-care and behaviour change. The aim is to reduce the risk of CVD (and reduce mortality rates for patients who have contracted it), improve the patient experience and reduce visits to Outpatient clinics.

14. Torbay Care Trust

This pilot will be integrating care for the elderly so that it is personalised and tailored to individual needs, secures best possible outcomes and ensures best use of resources. It will involve partner organisations across primary, secondary, social care and mental health services focusing on the whole care pathway, seeking to deliver high-quality, safe, and reliable services for patients across the spectrum of care.

15. Tower Hamlets PCT

This pilot will be helping patients with long-term conditions to manage their own care. It will help patients make their own choices, with support from a range of diverse services and specialists locally. It will aim to improve health and well-being for patients with long-term conditions, increase uptake of services from targeted hard-to-reach groups and reduce the expected trends in long-term conditions.

16. Wakefield Integrated Substance Misuse Service

This pilot will integrate care in the context of a substance misuse and social reintegration service for vulnerable people. It will involve a partnership of NHS, third sector and wider stakeholders and aim to make measurable improvements in the “care experience” for substance misusers, creating integrated pathways that are both personalised and cost efficient.

Pilots welcome as no one model of integrated care will work everywhere

King’s Fund Press Release | date: 01.04.09

Commenting in response to the Department of Health’s announcement today of new pilot schemes trialling the integration of different patient services including health and social care, The King’s Fund’s Chief Executive, Niall Dickson, said:

‘Bringing different services together in this way offers great potential for improving the quality of care patients receive. Too often boundaries between health and social care prevent people getting the care they need. Patients have to find their way around a complex system of doctors, community health workers and social care services when they should be able to talk to a single person about all their care needs. Some patients can end up blocking hospital beds when what’s best for them would be more support at home. And poor co-ordination between health services in the community and hospitals can mean unnecessary admissions and poor aftercare.

‘As more people live with long-term conditions, the challenges posed by chronic disease management and care planning will require services that are able to respond to the range of needs each patient has. Having a clear single point of contact for all services and ensuring better joint working between local health services and local councils should help people manage their conditions more effectively and receive more personal and convenient care.

‘The major challenge will be getting different health professionals – generalists and specialists, social care workers, community and hospital-based staff – to work more closely together. New and better types of care cannot be delivered simply by housing different professionals under one roof or merging multiple organisations. It requires bringing teams together, integrating the way staff work and creating new relationships between organisations.

‘It is also important that we do not create new monopoly organisations around the NHS that deny patients choice – we need services that are responsive and understand that either patients or commissioners may decide to go elsewhere.

‘It’s also important to recognise that there is unlikely to be one model that will work everywhere. That is why these pilots are to be welcomed but it is also why they will need to be thoroughly evaluated. The government has a habit of setting up pilots and then rolling out before lessons are learnt – that must not happen this time. This is a chance to learn genuine lessons about the best way to organise services.’

Notes to editors

  1. For further information or interviews, please contact The King’s Fund press and public affairs office on 020 7307 2585, 020 7307 2632 or 020 7307 2581. An ISDN line is available for interviews on 020 7637 0185.
  2. The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.
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The evidence base for integrated care

Posted on April 17, 2009. Filed under: Integrated care, Journals, News stories, Reports/papers | Tags: |

ripfA (research in practice for Adults) 

You can go directly to the evidence base but if this is your first visit or you would like more information please read on.

Welcome to the evidence base for integrated care which has been developed by staff at research in practice for adults and our Associate, Peter Thistlethwaite, in partnership with the Integrated Care Network (ICN). Peter is also author of the ICN’s A practical guide to integrated working (2008) which gives an overview of the theory of integrated working, examples of best practice models and relevant research and gives practical advice on how to initiate integration and evaluate existing partnerships. The evidence base can be accessed directly from the web version of the Guide on the ICN website, and vice versa.

The evidence base is aimed at staff in health and social care who are dealing with the integration agenda on a daily basis. It includes accessible summaries of the research evidence on integration, as well as key messages for practice. By providing summaries and key messages, we hope to provide you with information that can be used on its own, as well as signposting other relevant research, should you be interested in learning more.

The evidence base is being developed in stages and is due to be completed in November 2009. It currently includes relevant, good quality evidence published from 2007 onwards, but eventually it will include evidence published since 2000. Systematic searches are being carried out to identify studies providing original data about:

  • the impact of integration on outcomes for service users, carers and organisations
  • the effectiveness of different models for integration
  • factors supporting or hindering integrated working

Following a thorough literature search the identified papers are carefully selected in a two-stage screening process by two experts using stringent selection criteria. Selected papers are then carefully summarized to draw out the main findings and key messages in an accessible format. This will help you to access the most up-to-date evidence on integrated care in a quick and easy format. Summaries are fully referenced to enable you to locate the full text should you require more in-depth information.

If you are unable to find what you are looking for or if there is a study or other text you would like to recommend for inclusion, please contact us on 01803 860097 or

We advise you to find out more about the background to the development before proceeding to the evidence base.

To help you identify further background reading, we have included the bibliography of the Better Partnership Working series of books with kind permission of the authors (Glasby J, Dickinson H, Peck E, Carpenter J and Jelphs K) and Policy Press publishers.

Level of Integration

Area of Practice

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A practical guide to integrated working

Posted on April 17, 2009. Filed under: Integrated care | Tags: , |

Care Services Improvement Partnership  

What is integrated care?

Integrated care refers to advanced arrangements for joint working. In the context of this book the focus is on health and local authority care provision for children and adults, which at times will include Housing and Leisure services. The broad context of Local Area Agreements and joint strategic needs assessment which must underpin such collaboration is set in Section 5 of this guide.

What is the Integrated Care Network?

The Integrated Care Network (icn) provides information and support to frontline nhs and local government organisations seeking to improve the quality of provision to service users, patients and carers by integrating the planning and delivery of services. Key to the role of the icn is facilitating communication between frontline organisations and government, so that policy and practice inform each other effectively. The icn is part of the Care Services Improvement Partnership (csip).

Care Services Improvement Partnership

CSIP was launched on 1 April 2005 after a formal public consultation. Our main goal is to support positive changes in services and the well-being of:

• people with mental health problems

• people with learning disabilities

• older people with health and social care needs

• children and families

• people with health and social care needs in the criminal justice system.

ICN offers advice on partnerships and integration that cut across all services in health and social care. It works closely with other networks and programmes across csip to ensure synergy in improvements.

History of the guide

This is an updated version of Integrated Working: A Guide (2004). The contents of both versions have been devised and written by Peter Thistlethwaite, who is a specialist R&D consultant in integrated care. Like its predecessor, the new version has been designed and edited at Dartington Social Research Unit by Kevin Mount.

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