Press Release

TEAMS WITHOUT WALLS – WORKING TOGETHER WILL IMPROVE PATIENT CARE

23 April 2008

The success of providing ‘care closer to home’ lies in developing ‘teams without walls’ according to a working party of three medical Royal Colleges. Teams without walls bring together healthcare professionals from primary and secondary care to work across traditional health boundaries to deliver care that puts the patient first.

The working party, made up of representatives from the Royal College of Physicians, the Royal College of General Practitioners and the Royal College of Paediatrics and Child Health, suggest that jointly commissioned integrated health services should be provided by primary and secondary care working together.  An integrated model of care, where multi-professional teams work in a managed network across services and manage patients on a care pathway designed by local clinicians is the best model for the future.

The report stresses that clinical leadership is required if this approach to commissioning is to be successful and says that the incentives and disincentives of Payment by Results need to be re-balanced to bring integrated specialist and generalist care closer to the patient’s home.  The report suggests that the Department of Health should explore the idea of payment by pathway for an episode of care and annual payments by condition for long-term conditions.

Patients with long-term conditions move between primary and secondary care at different times of their lives and as they get older or more unwell these moves become more frequent and complex.  However, despite the need for services and healthcare professionals to work together, the current system based on demand management creates barriers between generalist and specialist practitioners.

Key features of successful integrated working identified by the report are:

• Clinical leadership and involvement
• High-quality partnership between clinician and professional manager
• Primary and secondary partnerships
• Committed commissioners willing to innovate and fund flexibly
• Clear patient focus for a defined group
• Clear governance arrangements
• Agreed measures and standards to improve the quality and quantity of work.

Elements that hinder integration are:

• Clear separation of managerial and clinical aims
• No clinical leadership
• Targets with unintended negative consequences
• A culture of competition rather than collaboration
• Financial flows that encourage efficiency without considering effectiveness
• A ‘command and control’ ethos that does not value learning.

Dr Rodney Burnham, Registrar of the Royal College of Physicians, said:

“ ‘Teams without Walls’ celebrates medical innovation and leadership and shows that generalists (GPs) and consultants (specialists) can work together effectively in one team with other health care professionals.  These teams are not bounded by institutions or bricks and mortar.  The care provided is high quality, sensitive and accurate along an agreed care pathway.  We believe that the Department of Health  and commissioners should encourage such medical innovation and leadership so that patients can benefit from the best clinically integrated care.”

Professor Steve Field, Chairman of the Royal College of General Practitioners (RCGP), says:

“ ‘Teams without Walls’ endorses a collaborative approach with strong clinical leadership, centering on the delivery of high quality, patient-centred care.

Developing closer working relationships between primary and secondary care clinicians – as recommended in the RCGP Roadmap to the Future of General Practice - will enable us to set up smoother care pathways and provide a wider range of integrated health services.

This is particularly important for patients who move frequently between primary and secondary care, such as those with long-term conditions and the elderly.”

Dr Simon Lenton, Vice President for Health Services, Royal College of Paediatrics and Child Health (RCPCH):

“‘Teams without Walls’ illustrates the power of clinical collaboration to redesign and improve the patient experience and outcome of services.  The future challenge is to align management structures, healthcare financing systems and commissioning strategies to promote this type of collaboration.  Patient care needs to be delivered by teams based on pathways within managed networks, unconstrained by traditional or organisational boundaries."

The report provides a range of examples of where integrated care has benefited patients. For example:

Gastroenterology in Barnsley

Patients with inflammatory bowel disease were educated and empowered to manage their condition without hospital attendance if they were stable. The results of blood test monitoring and advice were sent by email or text. This freed outpatient slots, saved an estimated £40,000 a year, and allowed rapid advice for patients suffering a relapse.

Shared scheme for patients with psoriasis in Manchester

Engagement led by a consultant, GPs, nurse specialist and patient group led to a randomised controlled trial of management of psoriasis in primary care. This assessed the effect of written guidelines and education on the appropriateness of referral to secondary care. The trial was successful and patients are now seen by the right person in the right place at the right time. Patient feedback has been positive, as has an audit of the quality of care provided.

Community children’s teams for life-threatening conditions – Lifetime Service, Bristol

Children with complex continuing healthcare needs often have acute exacerbations of their conditions that can be difficult to assess and manage in primary care due to their multiple co-morbidities. Community children’s nursing teams run from children’s departments, proactively plan for these problems, give telephone advice, and at the end of life provide 24/7 nursing care.

Cardiology rapid access clinic in County Durham

A PCT and trust funded a rapid access one-stop diagnostic clinic to assess patients with suspected heart failure and breathlessness. The clinic was run from the hospital with GP referrals, by a GP with Special Interest in Cardiology, supported by PCT-funded specialist nurses with a consultant cardiologist available for advice. Outcomes included reduced hospital admissions and high uptake of evidence-based heart failure therapies.

Musculoskeletal pain service in London

Collaboration between the PCT, local practices, an independent provider specialising in pain rehabilitation and a healthcare trust provides a patient-centred approach to improve the journey of people with low back pain. This includes a fast-track service for treatment or investigations as well as a Pain Information Afternoon with 70% of patients rated as excellent.

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