“Teams without walls”: An achievable ideal?

Integrated care, as described by the Department of Health (DH), is when both health and social care services work together to ensure individuals get the right treatment and care that they need. Although not always easy, I’m sure this is what we all strive to achieve. The DH is evaluating new ways of working together to achieve integrated care and pilot sites to test these initiatives will be identified by March 2009 (see http://www.dh.gov.uk/en/Healthcare/IntegratedCare/DH_091112 for further details). Integration, it states, “may refer to partnerships, systems and models as well as organisations; crossing boundaries across primary, community, secondary and social care”. Hopefully soon there will be practical examples from which we can all benefit.

While clinicians understand the need to work effectively across traditional boundaries, people with diabetes may be totally unaware that barriers to good communication exist. So concerned were they about restrictions to “seamless care” that Diabetes UK, the ABCD (Association of British Clinical Diabetologists), the PCDS (Primary Care Diabetes Society), CDC (Community Diabetes Consultants) and the RCN (Royal College of Nursing) Diabetes Nursing Forum published a joint position statement on integrated care (Diabetes UK et al, 2007a). That, in itself, demonstrated keen integration of health professionals and Diabetes UK! The paper was prepared in response to emerging evidence that redesign of diabetes services, effectively shifting more routine care into primary care, was, in some areas, being effected through cutting of specialist diabetes services (Diabetes UK, 2007). 

System reform tends to encourage unhealthy competition between healthcare providers (Young and Dean, 2006). Payment by Results (PbR) introduced a system of payment for specific episodes of care, such as outpatient appointments and inpatient stays. This is intended to clarify costs and assist movement of care from secondary to primary care. Savings made, it is suggested, can be transferred to primary or intermediate specialist services. A negative result is that PbR has encouraged competition between primary and secondary care, with hospital specialist teams feeling especially threatened (Royal College of Physicians [RCP] Working Party, 2008). As the RCP points out, PbR may create perverse financial incentives that influence the care we want to provide, both in primary and secondary care (RCP Working Party, 2008). They advocate “teams without walls”. This utopian ideal is the provision of an integrated model of care, where professionals from primary and secondary care work together in teams, across traditional health boundaries, to manage people with diabetes using care pathways designed by local clinicians.

The White Paper Our health, our care, our say (DH, 2006) recognised that more work is needed to support people with long-term conditions. It identified care planning as an area of good practice that improves integration and involvement of the person with diabetes. The Healthcare Commission review of PCTs’ performance identified that only 34–61% of people with diabetes nationwide have care plans (Commission for Healthcare Audit and Inspection, 2007). It appears we still have a postcode lottery with regard to healthcare delivery. 

There are, however, areas where integration is working, and areas where good examples may be gleaned. One example is the Year of Care (Diabetes UK et al, 2007b), a pilot project, involving three sites in England, which describes all the planned care a person with diabetes should receive over a year. Participants will adopt a care-planning approach involving agreed self-management strategies with individuals. Achieving this through the commissioning of appropriate services, and with limited resources, will be a challenge. 

Jill Hill’s article is therefore timely. Dealing with insulin pumps is a highly specialised subject, requiring particular skills and experience. Those of us in primary care need the support of, and must retain good working relationships with, our specialist colleagues, regardless of funding issues, to integrate and truly care for people with diabetes.