Patients at the centre: integrating primary and community care

Abstract

The quality and accessibility of healthcare services profoundly impact the lives of a country’s citizens. A well-integrated system of primary and community care is a critical part of these services. This report examines how we can ensure that primary and community healthcare services are readily available and seamlessly integrated, to provide holistic care for individuals and communities.

It is well known that the NHS faces major challenges, particularly within primary care. Originally devised to treat individual conditions, the NHS now serves a population which is living longer and includes many people with multiple health issues, requiring complex and continuous care. The NHS has failed to improve its organisational structure, funding mechanisms, infrastructure, and workforce to meet this challenge. As a result, it is ill-equipped to meet current healthcare demands, and its long-term sustainability is threatened.

The Committee heard how these challenges have severely impacted patients’ access and experience of health care. For instance, the British Red Cross explained why badly coordinated care leads to patients facing an avoidable health crisis and needing to present at A&E. Their experience encapsulates the problems faced by patients across the health service:

“When people talk to us … they tell us that they have almost reached that point of despair where they feel as though they are not able to access the services they need elsewhere. They are often turning to A&E because they feel as though, in their own words, they have nowhere else to turn … There is an issue there of people and the system not understanding the whole story and not seeing the holistic needs that sometimes make up the reasons why people fall into crisis.”1

Patients are constantly being inconvenienced, endangered, or miss improved long-term health because they are not receiving joined-up care, in the right place, at the right time.

Integration can help improve patient experience and offers a viable solution to many of the challenges facing the health service. Integration can be broadly defined as the way that different organisations can work together to deliver well-coordinated healthcare, which is designed to meet patient health needs. Integration can help improve poor public health outcomes by making healthcare more preventative. This in turn can help to reduce high demand for reactive health services. Better integrated care is often more time and resource efficient, which can also help address funding shortages. Patient pathways (the course of care that patients receive as they move through the health system) are often fragmented, but integration helps ensure that patients are treated by the right clinician at the right time. Better integrated care can also give more autonomy and responsibility to individual clinicians, increasing workforce morale and encourage retention.

Poorly coordinated care significantly undermines the quality of patient experiences with NHS treatment and can have profound consequences for their long-term health. This Committee has heard of patients suffering vision loss or facing critical delays in treatment due to the mishandling or loss of healthcare records between services. Patients in care homes frequently endure inconvenient and often unnecessary trips to see their GP or for hospital appointments due to the unavailability of online consultations with clinicians, or the lack of consistent access to a community nurse.

Patients are being deprived of the benefits of readily accessible, preventive, and highly effective community care services due to space constraints within the primary care estate, or because of a shortage of healthcare professionals. Additionally, the delivery of complex care is fragmented across various services, which do not coordinate to plan overall patient care and recovery. This must change to ensure that patients experience a health service, rather than a sickness service.

Four key obstacles—structures and organisation, contracts, data-sharing, and workforce hinder the implementation of integration policies in the health service. This report addresses each obstacle and puts forward recommendations to mitigate their effects.

Structures and organisation: effective health service integration relies on professional relationships between services as much as formal structures or policies. While the Health and Care Act 2022 encourages local autonomy and subsidiarity, designing a universal policy to encourage constructive inter-service relationships has proven difficult. The collaborative ethos behind the new Integrated Care Systems (ICSs) is evident. However, imbalances between the power and representation of Integrated Care Boards (ICBs), Integrated Care Partnerships (ICPs), local authorities and voluntary, community and social enterprise organisations (VCSEs) within ICSs limits integration. The Committee proposes that ICSs should be given time to mature. Rather than implement further wholescale reorganisation to the health service, the membership of their governing bodies should be widened, and accountability should be enhanced through better inspection.

Contracts and funding: the NHS allocates an excessive amount of funding to reactive hospital care, at the expense of preventative primary and community care. Service contracts lack incentives for multi-disciplinary care, particularly in pharmacy, optometry, and dentistry, leading towards reactive rather than holistic care. Contract reform is needed to ensure that multi-disciplinary work is incentivised. Co-location, or housing multiple healthcare services under one roof, encourages better communication among professionals, easier access for patients and therefore better-integrated, patient-centred care. However, the existing GP contract and partnership model hinders co-location and therefore changes to these need to be investigated. Fragmented funding across different healthcare disciplines also impedes multi-disciplinary integration. A significant divide exists between social care, funded by local authorities, and primary and community care funded by ICSs. There have been efforts to bridge the funding disparities between the NHS and local authorities, notably the Better Care Fund (BCF), but existing payment systems and contracts have curtailed the effectiveness of these efforts. Joint funding models need to be enhanced to overcome this.

Data-sharing: witnesses emphasised the importance of robust data collection, sharing, and analysis for successful healthcare integration. Single Patient Records (SPR), which consolidate patient data and make it accessible across various health services, have not been universally adopted. Full implementation faces hurdles, including data interoperability issues (the ease with which different computer systems can communicate) and widespread IT inadequacies affecting data exchanges. Clinicians contend with significant technical barriers in data sharing, with outdated and incompatible systems. Fragmentation of data systems complicates patient pathways, with risks of data loss or repeated patient questioning between services. While technological solutions are available, data sharing is also hindered by cultural and perceived legal obstacles. Clinicians are often hesitant to share data at the risk of contravening GDPR and other data protections laws. Although legislation requires ICSs to share data, cultural attitudes lag behind this and so guidance on data sharing need to be clarified.

Workforce and training: a shortage of staff makes integration more difficult, as staff are required to spend more time meeting everyday demand, rather than proactively implementing new integration strategies. Specialised staff are not trained sufficiently in the work of other clinical disciplines and there are perceived hierarchies of professions and services. There is a need for integration to be included in initial clinical training and for clinicians to be introduced to the work of other services through job rotations. Social care is an important partner with primary and community care yet is not sufficiently integrated with them. Better training for social care workers would enable them to work more effectively with primary and community care. Social care needs to be included in the NHS’s Long Term Workforce Plan to ensure that enough well-trained social carers are available.

The Committee found that trusting and constructive working relationships, aligned contracts and funding, and seamless data sharing are essential for integration. By removing obstacles to these, services will be better integrated and some of the major challenges facing the health service can be addressed. We urge the Government to build on its work on the integration of primary and community care and to implement the recommendations in our report, so that our crucial health and care services can evolve to meet the increasingly complex healthcare needs of our people.

More information

Identifiers

ORCID for Lindsey Cherry: orcid.org/0000-0002-3165-1004

Catalogue record

Export record