Better integration of health and social care services is a critical part of delivering efficient user-centred care.
By working together, NHS organisations and local government can help reduce hospital admissions and ensure that more people receive high quality care in community settings.
For patients and services users, integrated care means being at the centre of their own care, and not having to re-state personal details, symptoms or needs several times, or falling between gaps in disparate services or suffering from uncoordinated visits to different services.
For local Clinical Commissioning Groups (CCGs) and Councils, integrated care is likely to mean the realignment or redesign of services and sharing of some budgets.
NICE has an important role to play in supporting local organisations to integrate their service delivery, and in particular to support CCGs and Councils in the process of submitting plans to the Government’s £3.8bn Better Care Fund.
“NICE is well placed to be the first port of call for any local NHS organisations or Councils looking to provide integrated care,” says Professor Gillian Leng, NICE’s Deputy Chief Executive.
“Our evidence-based guidance and quality standards set out what high quality care looks like across a variety of providers and settings. What’s more, we provide a variety of resources and support to help drive change at a local level.
“For example, our Local Practice Collection brings together hundreds of case studies highlighting projects happening around the country to improve the quality of care commissioned and provided.”
Eighteen examples in NICE’s local practice collection highlight projects already underway where integration of services has led to improvements in quality and productivity:
- Alcohol Care Teams: to reduce acute hospital admissions and improve quality of care
Royal Bolton Hospital NHS Foundation Trust and the British Society of Gastroenterology
A multi-disciplinary Alcohol Care Team worked across hospitals and primary care to develop a coordinated approach to alchohol treatment and prevention, including organising systematic interventions and access to specialist advice and treatment. The initiative address alcohol-related problems more effectively, reducing hospital re-admissions and discharge times, and improving patient outcomes.
- Improving the quality of care for patients with type 1 diabetes: dose adjustment for normal eating (DAFNE)
Department of Health
DAFNE is a five-day structured education programme for adults with type 1 diabetes, providing knowledge and skills for dietary carbohydrate management and insulin-dose adjustment. Introduction of the training programme showed a significant improvement in patient safety and a reduction in adverse events, such as hypoglycaemia. There were also sustained improvements in patient quality of life and treatment satisfaction, due to fewer hospital visits and admissions.
- Improving the quality of care for men with lower urinary tract symptoms: shared decision making
South Norfolk Healthcare Community Interest Company
This programme focused on the quality of decision-making between clinician and patient, by providing feedback to individual clinicians, supported by educational materials that were based onagreed quality markers from NICE guidelines. The initiative reduced time delays that oftenresult from incorrect disgnoses and referrals, as well as increasing patient safety by improving assessment in primary care.
- Peer-reviewed referral management: saving money and increasing quality by improving referral practice
South Norfolk Healthcare Community Interest Company
Focusing on improving the quality of elective referrals in primary care, this initiative peer-reviewed GP referral data and disseminated timely feedback where the referral could be altered. This resulted in an overall increase in patient safety and fewer adverse events, due to more appropriate referrals. Referral waiting times were reduced, particularly for patients judged to be at high risk of cancer.
- Rapid Response Services: intermediate tier, multi-disciplinary health and social care service
Care Services Efficiency Delivery Programme (CSED-DH) in partnership with Bristol PCT and Bristol City Council
Rapid Response Services are multi-disciplinary teams that work to provide alternatives to unscheduled hospital and residential care admissions for older people, typically through at-home care. The service operates at an intermediate tier between acute and primary care, and provides an integrated approach across health and social care.
- Stratified cancer pathways: redesigning services for those living with or beyond cancer
This initiative improved after-care services by matching the level of support to the patient's individual needs and preferences. This included supporting patients to self-manage their own health and wellbeing once treatment had been completed, and acute after-effects had subsided. This released outpatient resources, allowing patients with complex needs to access specialist teams, and enabled patients to address their own unmet needs.
- Safety Express: a national pilot to deliver harm free care
QIPP Safe Care Programme, Salford Royal NHS Foundation Trust and University of Central Lancashire
This programme required organisations to address high-level factors - leadership and safety culture, 95% reliable clinical care, and support infrastructure - that influence the delivery of harm-free care, defined as absence of pressure ulcers, falls, urinary tract infections, and venous thromboembolisms. The NHS thermometer was used to monitor patient harms, and showed significant reduction in all four harm areas.
- Home administration of intravenous diuretics to heart failure patients: increasing productivity and improving quality of care
British Heart Foundation
A pilot programme assessed safe and effective ways for specialist nursing teams to administer intravenous diuretics to heart failure patients, at home or day care settings. Home-based treatment was reported to be less disruptive for the patient and enabled discussion of wider treatment and condition-management, improving patient and carer experience.
- Reducing hospital admission rates for people with diabetes: a systematic approach to improving primary care outcomes
This initiative used the established NICE Into Practice guide to provide a structured programme of cardio-metabolic risk management and improve the health outcomes of high risk patients, particularly those with diabetes. By effectively implementing NICE guidelines, and systematically improving patient outcomes in primary care, the programme aims to reduce hospital admissions.
- Management of patients with stroke: REDS (Reach Early Discharge Scheme)
CNWL NHS Camden Provider Services
The Stroke REDS team provides intensive home-based rehabilitation to stroke patients who are suitable for early discharge, before supporting transfer to the REACH community team for long-term rehabilitation. The initiative improved patient outcomes and safety by reducing the length of stay in hospital, promoted patient independence at home, and supported effective transfer of care.
- Early discharge and intensive community rehabilitation for stroke patients
Berkshire West PCT
The Early Supported Discharge (ESD) Team facilitates transition from the intensive rehabilitation received in acute stroke units to long-term support in the community. The ESD Team provides multidisciplinary rehabilitation at home after discharge, for up to six weeks. The programme reduced the average length of stay by eight days per patient, as well as reducing re-admission rates and occurrence of adverse outcomes and secondary cerebral events.
- Enhanced home-based palliative care for adults
Bournemouth and Poole Community Health Services
A nurse-led community palliative care unit was established to provide enhanced home-based care for patients with end-stage life-limiting illnesses. The unit allowed for complex care packages to be provided in patients’ homes, and enabled greater mitigation of risk and crises, which may result in hospital admissions.
- Care in the home schemes
British Red Cross
Red Cross volunteers and staff worked in partnership with NHS services to deliver care in the home schemes that reduce hospital admissions and re-admissions, and promote timely and effective discharge.
- Self care support for long term conditions
Department of Health
A campaign from the Department of Health was aimed at educating patients with long-term conditions about their disease, treatment choices, and care pathways; policies and common core principles were also introduced to support service redesign. The initiative has been replicated across the UK, embedding patient choice and support for self-care as an integral part of care pathways.
- Personalised care plans for long term conditions
NHS North East
People with long-term conditions should be offered a systematic planned assessment of their overall care, their ongoing needs, and their forthcoming care. Personalised care planning is central to improving patient involvement in care and decision making, leading to enhanced quality of life and patient outcomes. Personalised care planning has been effectively implemented in a variety of settings, notably in supporting patients with diabetes.
- Self management for chronic knee pain: using group physiotherapy to teach exercises and coping strategies
Sevenoaks District General Hospital
Pain-induced limitation of mobility and physical function, resulting from chronic peripheral joint pain, increases the risk of exacerbating or developing co-morbidities. NICE guidance recommends that exercise should be a core treatment of osteoarthritis. This rehabilitation programme combines education, self-management, and coping advice with an exercise regime tailored to address the patient’s needs.
- Podiatry education to empower patients to self-care
Community and Primary Services, Sheffield Teaching Hospitals NHS Foundation Trust
Many common foot problems, typically presented by elderly patients, can be treated by the patients themselves, once they have the confidence, skills, and knowledge. Patients identified as suitable for self-care were invited to attend an awareness session delivered by a podiatrist, allowing the podiatry service to concentrate care on high risk patients, such as those with diabetes, without any detriment to patients discharged to self-care.
- Pre-emptive occupational therapy for healthy older people
College of Occupational Therapists
A programme of preventative occupational therapy for healthy older people can promote quality of living and health, and reduce the need for other medical interventions. A pilot programme has been undertaken to demonstrate promotion of successful and healthy ageing.
For practical, hands-on support for integrating services locally NICE has a dedicated field team of implementation consultants. Our field team works with people at a local level to help inform them about putting guidance into practice, to keep them up to date on what is relevant to them from NICE, and to help share and spread good practice. Each consultant links with social care, the NHS, local authorities and other organisations in their area, and gives them a chance to feedback to NICE on things that we could do better to meet their needs. If you would like to meet your local NICE implementation consultant please contact the NICE Field Team.
Organisations interested in using high quality, authoritative evidence to plan services locally can also use NICE Evidence Services, a free online portal providing access to trusted and accredited sources of evidence across health, public health, and social care.