Integration from a general practice perspective

• Written by: Dr Graham Kramer — Royal College of General Practitioners Scotland, Patient Partnership in Practice — Executive Officer
• Published: 17th June 2018

The concept of integration and its ethos has been broadly welcomed by GPs.  However, there are numerous challenges to overcome.

The Christie Commission (this link will take you away from our website) published in 2011, set out the challenges facing our health and care systems.  It challenged us to overhaul the top-down relationships of our traditional, complex and fragmented, system to a new order of integrated collaborative partnerships.  It recommended building systems of care from the bottom up in a co-productive approach between multi sector resources and communities, supporting and building resilience and realising assets and talents.  It was the birth of what we now call Health and Social Integration.  In the two years since integration there has been significant energy around governance and fiscal arrangements in the strategic “sunlit uplands” of regional authorities but what effect is this having down the line?  This article takes in the view as seen from the relative “swampy lowlands” of General Practice.

General Practice has traditionally seen itself as a holistic resource that looks beyond the biomedical concerns of people to embrace the social and emotional contexts of wellbeing.  However, if we are honest, the shifting nature of GP caseloads has threatened the holistic essence of family practice.  This workload shift includes the ever increasing medical and technological responses to illness; contractural guidelines for long term conditions; and sicker, older and frailer people being cared for at home.  Practice, if anything, has become more reactive, with, frustratingly, less space for proactive planning.  The personalised approach of Dr Finlay has being replaced by a more industrial model.  However, GPs have long recognised that the “pill for every ill” approach is limited, unsustainable and a soulless way to practice medicine, not to mention for those on the receiving end!

In this respect, the concept of integration and its ethos has been broadly welcomed by GPs. However, it has created numerous challenges to overcome before we can all arrive at the well functioning health and care “Nirvana” envisaged by Christie.

Multi-agency working is a complex process of communication and relationship building, which takes time along with new collaborative leadership skills, attitudes, and opportunities. This can challenge mindsets and systems, which have been hard-wired to previous ways of working. Team working can complicate communication, action, and continuity of care. IT may help all this, but systems need to join up and talk to each other, mindful that they must promote rather than replace relational care.  It’s also a big change for individuals and communities with an expectation that it’s in their best interest that they become active partners rather than passive recipients of care and services. Encouraging and supporting them in this new role is hard and takes time, being aware that people differ in motivation and capabilities. How we respond to these differences is key.

Welcome initiatives are aligning themselves to support General Practice with integration. Leadership support and training through the “You as a Collaborative Leader” initiative developed with the Scottish Social Services Council (SSSC), NHS Education for Scotland (NES) and RCGP Scotland has been insightful. The ALLIANCE-led House of Care Scotland Programme is helping practitioners and their patients living with long term conditions to proactively plan care together, in ways that support people to self manage.  These conversations are a crucial mechanism by which we identify the needs of individuals and are therefore critical to informing how our health and care system responds.  The Links Worker Programme and the ALISS project are helping us to understand how we build connections, knowledge and partnerships with community based self management support.  The new GP contract is set to encourage multiagency collaborative working.  Data gathering and sharing is looking promising.  Developments such as Scottish Primary Care Information Resource (SPIRE) and the support of NHS Information Services Division (ISD) ‘Local Intelligence Support Teams’ will be invaluable.  It’s important to recognise that beyond these national initiatives there are many good examples in General Practice of local collaborations.

The learning so far is that it’s all going to take time before we see measurable change.  At the moment few of us have the vision or understanding of what integration and its benefits could look like. There is a worry that GPs and their teams will struggle to find the time and capacity for the necessary leadership to move from their current, entrenched systems and structures.  Promoting a more social model of care will also need investment and a courage to shift money and resource beyond traditional “services”.  Whilst fiscal restraint may be a driver for integration it will not facilitate it.  It will require those who hold the budgets and control to listen to, trust, support and empower local teams who are delivering services in order that those local teams can reciprocate with the individuals and communities that they work with.  It’s all about relationships and how we facilitate them.  Examples of it working well can be seen in practices co-located with care professionals and support workers, with frequent formal and informal meetings and “virtual ward rounds”.

I remain optimistic that Scotland, with its communitarian and rights-based ethos, manageable size, and dedicated workforce, is well on the road to maximising the benefits that integration will bring.

Dr Graham Kramer can be found on Twitter at: @KramerGraham (this link will take you away from our website)

Graham’s Opinion is part of the ALLIANCE’s ‘We Need To Talk About Integration’ anthology which is available at the link below.

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