Collective Intelligence speeds transition to integrated healthcare for a place-based health and care system in England

For years, health care and social work professionals in England have understood the inefficiencies and increased risks of delivering care in a system of doctors and caregivers — along with their respective organizations — all working separately. Patients’ needs often overlap the organizational boundaries that prevent professionals from working together to provide high-quality care.

The government is so keen to establish integrated care that in 2015 the National Health Service (NHS) set out a requirement for all local health and social care systems to be integrated by 2020.

Though the desire to deliver “joined-up” care has been present, along with regulatory pressure to get it done, many communities have been stuck, unable to unlock the behaviors that were preventing this desired transformation.

How We Helped:

Unraveling the complexity by identifying barriers and opportunities

Optimity worked with the leaders from across the local system, to help them implement their vision for a new integrated system-wide model of care including both physical and mental health. Our first step was to get people from all relevant groups in the same room and identify what was getting in the way of making progress. These participants included representatives from the hospital, community services, mental health services, the council and general practitioners. Although these groups had convened for discussions before, little progress had been made to deliver observable change at scale.

Optimity Advisors worked with senior leadership to unlock areas where they had local control, identify what could not be changed, and develop workarounds that would enable individual providers to engage patients in a coordinated approach. 

We also conducted research to understand the needs of the population and what was standing in the way of integrated care. After analysis, among other opportunities, we identified a group of patients with multiple long-term conditions — the highest cost users of the system — and suggested that significant costs could be saved by better managing just this one population. This approach of addressing needs proactively by integrating various types of health care providers with social services became the blueprint for the whole system.

Results/Impact:

Better care, lower costs, safer and happier patients

How does integrated care look in practice? Here’s one example. Prior to achieving an integrated care approach, a care home resident with a spike in temperature due to a urinary tract infection would have been sent straight to the hospital. But with joined-up care, the patient is seen by a rapid response team made up of specialty nurses, pharmacists and general practitioners dedicated to that care home. Together, they can assess the patient and prescribe medication to keep them in the care home rather than admit them to the hospital.

Throughout the project, Optimity helped decision-makers navigate through complexities and start to embed a culture of testing, innovation and taking more operational risks. Optimity also helped the system leaders identify new ways of incentivizing and reimbursing new models of integrated care. As a result of the work we did together, the model changed, shifting from top-down dictation and compliance to creating an approach that puts the patient at the center, and coordinates the separate care teams to support that effort.