Everyone agrees that coordinating care around the patient is important- so why does it keep on not happening? 2

Start helping it happen by putting patients at the core of drivers for change

The integration of fragmented NHS services with social care has been policy since 2006. We therefore have some experience of what works and what doesn’t. (As I said yesterday one thing that conspicuously does not work as a main driver for change is ‘having a policy’). Therefore, if the NHS wants to develop greater coordination of services around the person over the next 10 years we have some experience of how to do this.. And this is not just an argument that takes place within ‘policy’ but is a set of experiences about practice..

Whilst the argument for coordination is usually a moral one – the right thing to do is to put the public at the centre of service delivery – in developing person-centred coordinated care it is also a material argument. Fragmentation uses a lot of extra resources that the NHS cannot afford. The argument for coordination is therefore also an economic one against waste.

This moral and material argument and practice against fragmentation is now taking place at every level of the NHS and social care.

It is taking place within institutions that themselves fragment services. Many organisations that fragment care recognise the problems caused by that fragmentation at the thresholds of their organisation – where they come up against other NHS or social care organisations. When the public are handed over (or more likely not handed over) from one organisation to another there are thousands of slips every day. Problems of data, problems of medicines management, and problems of different and sometimes contradictory advice from the different institutions – all cause real problems for the public in dealing with each institution. So even within their little bit of the pathway they are trying to coordinate better. Last winter’s concerted attack on delayed transfers of care was an attack upon this issue of thresholds.

In many localities different parts of the services are trying to bring a number of organisations together. Some of this coordination comes from local leadership and initiatives around pilots and vanguards etc.; some of it springs from national initiatives as the Better Care Fund – but all of it means that on a daily basis many localities are struggling to deliver much better coordination.

Above this, at STP level, there is a policy/institutional level where fragmentation is being confronted and there is a strong expectation of working together from above. (Even when different bits of the performance management ‘above’ stop you from doing it.)

At all these levels staff and leaders are trying to overcome fragmentation where the argument has been won – if not the nature of practice changed.

Over the last five or six years, I have been working with leaders in all of these different levels of public services where they are trying to coordinate better care. The most obvious thing to say is that it is always a very hard and difficult process of change. There is a paradox here. Because ‘everyone’ is talking about developing coordinated services, everyone seems to think this should be easy. Then when people find out what it is, they discover that it’s very hard. When people find it hard, they think they are in some way feeble – because surely it’s meant to be easy?

But in reality all of this change is hard – hard at the STP level – hard at the level of locality or place and hard at the level of single organisations. Coordinated care challenges and turns over the way in which we work round here and have worked round here for 70 years. Over any period of time it is exhausting.

And this brings me to my main argument about the way in which we need to help localities change. When the five year forward view was launched there was some discussion about developing renewable energy to help start and continue change. The need for that renewable energy was included because we know how exhausting this change can be.

And the main source of renewable energy in the drive for person-centred coordinated care comes from the public. How do the public provide energy for change? First the public need to be genuinely allowed into the process.

For example it is their lives, the lives of the public that contains the main critique of the fragmented care of the present. Over and over again we know that it is the bad experiences of the public that provide the initial and continued impetus for change. If we exclude them and their stories from the process people will say on a strained Thursday afternoon, “Why – really why – are we doing this very difficult stuff?”. And if the answer comes back that it’s because the five year forward view tells us to, it doesn’t really provide much motivation. However if, on that same Thursday afternoon someone in the room can say “the reason for this change is so that 85 year old Mrs Jones will be able to continue to be independent because she won’t spend 10 days in an emergency care bed” the realisation and motivation are clear – “Ah yes that’s why we are doing it!”

But that means allowing the public into the room and everyone recognising that the reasons you are doing this is NOT an internal problem for public services – but a real ongoing day to day problem for the public.

Yet when you read plans for coordination they usually start off by saying the problem is that there are too many people in emergency beds. Yes that is a problem – but it’s a problem for the services themselves.

The problem for the public is the experience of older people losing independence because they spend 10 days in hospital beds. These can sound as if they are the same thing but actually they are not. One is our problem the other is theirs.

The moral purpose of putting their problem at the centre of the change process is to give everyone that renewable energy for change.

But this will only happen if the public and their problems are allowed into the room. The paradox is – if we exclude them from the room of change – we exclude the moral purpose for change that comes from their stories and their lives.

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