Effective integrated care has been a national policy ambition for many years. At CQC we have just published our report on integrated care for older people Building Bridges breaking barriers, looking at how well health and social care services work together to deliver integrated care for older people.
People who have complex needs, and rely on care from a range of different services, often say they 
are very satisfied with the care they receive from each individual care provider. However, given that many of them move between services or care professionals, their care can often become fragmented.
Older people typically have the most complex care needs and consequently receive care from more than one provider and in multiple settings. As our older population is growing, it is more important than ever that care systems work together.
We found that:
There was widespread commitment to delivering integrated care and a belief that it is improving. However local leaders still struggle to translate this commitment to an understanding for staff about how services work for older people across a local area, and within organisations, and how they can collectively provide integrated care.
There was no single mechanism for identifying people at increased risk of deterioration or at risk of admission. Each organisation in an area used separate risk profiling tools with no sharing of information. Information sharing between organisations need to improve to reduce repetition, improve use of resources and prevent the patients constantly need to repeat their stories.
“[Telling the same story again and again] becomes draining and you end up just wanting to get out ASAP. How can a professional come to an appointment without some information?”
There is work to be done on care plans. Some areas were working to produce a single care plan that was recognised by all agencies, but in many areas we found that patients had multiple care plans that represented an organisation approach rather than one that was person centred. In line with National Voices policy CQC will only recognise care plans that have involved the patient or those important to them in writing them. Anything written by health or social care with no meaningful patient or those important to them involvement should be called treatment or management plans.
“I’ve recently been sent a care plan from my GP however I find it is not simple to understand and not very informative. I would rather have my own input into my own care plan and flag my vulnerabilities such as my asthma, my broken hip, my gallstones, my achy shoulder, my allergies to penicillin rather than having something that somebody cannot understand if they find me in an emergency”
The lack of connection between services often resulted in older people and their families/carers needing to take responsibility for navigating complex local services. This could result in people ‘falling through the gaps’ and only being identified in response to a crisis.
“People fall off the radar once they have progressive disease. At the start (diagnosis) there is a flurry of activity, then this drops off. If someone has managed and not shouted for more help and support, care then appears to stop. It would be better to have an expectation that a need for care is recognized and in place”.
Older people were not routinely involved in decision making about their needs and preferences. Many professionals did not know how to enable people to make informed choices and some had concerns about the risk of people making such decisions.
“When I have been in hospital for an appointment the consultant always says we will write to your GP and he will explain – why can’t they tell me right there?”
CQC have made several recommendations as a result of this report and are also updating their inspection methodology to take into account the findings of this report.
- Locally, health and social care leaders build on the opportunities offered by initiatives such as the Five Year Forward View Vanguards and the Sustainability and Transformation Plans to develop and agree a shared understanding and definition of what integrated care means for their population in their local area, and then work towards delivering this shared aim.
- An agreed methodology is developed at a national and local level across health and social care for identifying people at risk of admission to secondary care or deterioration.
- Older people are meaningfully involved in making informed decisions about their care needs and care planning – in particular about the outcomes that are important to them – based on the existing national and local guidance.
- Commissioners and providers in an area ensure that information and support for older people and their families/carers is available and that this sets out what details of what services are available, connections between different services, and how peoples’ accessibility requirements will be met.
- A set of validated data metrics and outcomes measures for integrated care are developed and shared, with person centred outcomes being at the heart of decision making about service provision and being based on a consistent, shared view and definition of integration.
More information on what these recommendations mean in practice for each part of the system can be found by reading the report on the CQC website.
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