King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.
Who should lead the integration of services?
According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.
Integrations call for time and tenacity
Based on the fact that each integration project is based on the logic of a particular clinical process, the teams ought to be cohesive stimulated by the quality of their work, by the increased involvement of patients and by the results. In reference to the 5 examples above, these are all long-range projects that have been or are being consolidated and rely heavily on the tenacity of the professionals and their shared vision.
The financing models should be adapted to the integrations
The ways in which the providers charge for services are still too anchored in the past, while the new proposals don’t seem to sink in. To put it more clearly, hospitals continue to be encouraged by the activity, health care workers - by occupation and primary care - by the number of patients. The new financing models tend to shape this starting point, but now what would be convenient would be forms of payment that would encourage disruption by encouraging the integration of services.
Outsourcing and the roles of professionals should be reviewed
Professionals should be assigned to integrated services, not to traditional services. Therefore, it should be ensured that labour recruitment models are jeopardising multidisciplinary teamwork. Experiences should go beyond coordination based on assigned professionals. Conversely, it’s desirable that the new integrated teams are strengthened by the management of their own resources, including the allocation of professionals.
Territorial managements and integrated health organizations are a step forward, but now, moreover, we need to prove that they are useful for disruptive innovation and the King's Fund's document faces us with strategic duties: defining integrated clinical processes; assigning professionals, involving patients, allocating own resources and demanding results.