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Putting the pieces together: Removing the barriers to excellent patient care

All parts of the health and social care system have a crucial role to play in leading the change needed to improve patient care, foster a sustainable and efficient NHS, and meet the growing and more complex care needs of communities.

As the RCP’s independent Future Hospital Commission6 set out in 2013, we need to dismantle the barriers to joined-up patient care. Commissioning, contracting and funding arrangements must empower the different parts of the health and social care system to work together, flexibly and sustainably, for the patients of today and of the future.

Yet the doctors, managers and commissioners who lead our NHS face unnecessary barriers to making this vision a reality. Physicians on the front line of patient care have highlighted some of the key challenges.

Systems and structures must support joined-up care

We must empower commissioners to collaborate In most areas of specialist medical care, there are structural divisions in commissioning between the NHS, public health and social care. This means that different organisations are responsible for commissioning different sections of the patient pathway – from NHS England, which commissions highly specialised care, to CCGs, which commission local health services. There are many excellent examples of commissioners working together across these boundaries, delivering innovative and joined-up solutions to healthcare challenges.

In Sheffield, for example, the CCG and the city council are working towards joint commissioning in major areas of care, including emergency admissions. In Greater Manchester, emerging plans for ‘Devo Manc’ aim to bring together the city region’s £6 billion combined annual health and social care budget and, ultimately, to plan and commission all health and care in a joined-up way. Nationally, the growing involvement of CCGs in the commissioning of primary care and specialised services is an important development, and one that has the potential to help join up patient pathways in many parts of England.

However, research from The King’s Fund suggests that integrated commissioning (not to be confused with integrated care) remains rare, and tends to be restricted to a small number of service areas. The intensive work, negotiation and innovation required to achieve joined-up commissioning pose a substantial barrier to already stretched commissioners who are also grappling with financial challenges and rising demand. Put simply, ‘some local commissioners may not have necessarily had the time or been equipped with the knowledge and skills to commission in collaboration with local partners to take a whole-system approach’.

There are well-documented examples demonstrating how this can lead to disjointed care and fragmented clinical pathways. In some areas of patient care, physicians have found that services are planned and commissioned in a fragmented way, looking at one small part of a much wider patient pathway without due consideration of other, closely related areas of patient care. Without clear lines of accountability for each part of the patient pathway, this process can disrupt patients’ experience
of care. At its worst, this can lead to unnecessary referrals, delayed diagnoses, and patients ‘lost to follow-up’ as they struggle to negotiate the complexity of accessing many diverse services, often in different places and with different healthcare professionals.

In the most concerning cases, fragmented lines of accountability have meant that patients are unable to access services at all.