Integration is about patient care pathways

12 March 2021

Integrated care is a good thing. It’s certainly better than fragmentation. And that’s why we’re talking about it again, especially in England with the publication of the recent White Paper, Working together to improve health and social care for all.

But the fact that it’s a good thing doesn’t mean it will happen. An international systematic review of carefully planned initiatives to improve integration, published in 2008, found that only a half of them improved health outcomes or patient experience and less than a fifth reduced costs.

And our experience in this country mirrors that evidence. By my reckoning the White Paper is the most recent of nine high profile national policy initiatives to promote better integration in the last two decades. The need for repeated efforts in any field usually suggests that something isn’t working. It feels like another manifestation of King Charles I's mournful reflection as he was led to the scaffolds in 1649: "I now know there’s more to the doing than bidding it be done".

The answer? Stop talking about legislation and strategies and structures and governance and instead focus on what’s happening on the front line where patients and health professionals interact. Integration is about patient care pathways. Create space for patients, primary care and hospital clinicians to sit down together with local managers and we know from many examples across the country that they can eliminate fragmentation. It’s not easy but it can be done. 

Latest updates from your College

Vaccination passports

As I mentioned last week, we’re taking a keen interest in discussions about the possible introduction of vaccination 'passports' and I’ve now written to Cabinet Minister Michael Gove who’s leading the review in England.

The College is asking for a number of principles to be incorporated into any proposals to ensure there are no unintended negative consequences for general practice or our patients.

Critically, any system put in place for vaccination certificates must have 'zero-impact' on GP workload and the extraction of vaccination data should fall outside of GP data flows. We’re already facing worryingly high workload pressures, which will continue to rise as we deal with the fallout of COVID-19, including backlogs of non-COVID related care and emerging issues such as 'Long COVID'.

If the NHS App or another digital platform is used as the primary mechanism for the certificate, alternative systems must be put in place to support equal access for those without the relevant digital access or sufficient digital literacy. Without this, there will be an unfair access divide amongst the population and health inequalities will worsen.

Any system implemented must also protect the privacy of the individual and be as technically hard to fake as possible - and it must be optional for patients.

In my letter, I’ve told Mr Gove that the College and GPs need to be consulted as part of his review and have said that if the scheme is taken forward in England, it’s essential that the devolved nations are consulted as part of the process.

I’ll let you know when we get a response.

Homeless people become vaccine priority

We’re glad to hear that homeless people have now been added to the JCVI vaccine priority categories. The College has been highlighting the importance of this, in the interests of vulnerable individuals and public health, so this move is a welcome one.

We continue our work to increase vaccine uptake amongst vulnerable groups and Victoria Tzortziou-Brown, the College’s Joint Honorary Secretary who works in East London, has asked me to draw your attention to our new eLearning on Health Inequalities and Vaccinations.

GP records and long-term effects of COVID-19

Coding within GP records is obviously crucial to enable us to understand the true prevalence of COVID-19, as well as to ensure adequate funding for general practice.

Our Research and Surveillance Centre (RSC) has put together this excellent 'crib sheet' that we hope will help. It also includes the medical terminology now in use, in line with national guidance written by RCGP/SIGN and NICE.

The RSC is growing rapidly and is always keen to recruit more practices for its valuable work.

Lymphadenopathy - possible vaccine side effect

Evidence is emerging of around 10-15% of patients getting enlarged lymph nodes in their armpits after vaccination. This is transient and lasts a few days.

However, it has prompted concerns about misinterpretation in women attending for mammography, with some suggestion that either vaccination or mammography should be delayed.

Given the importance of both vaccination and mammography it is important that both procedures go ahead and that patients and clinical staff are aware of this side effect when offering and interpreting mammography.

New research on Pfizer vaccine

I’m sure we were all disappointed to see the results of the study by King’s College London and the Francis Crick Institute, published yesterday, which disputes the efficacy of the first dose of the Pfizer jab for cancer patients. The authors are now calling for a review of the vaccine schedule and a much shorter timeframe between the two doses.

As you know, the College publicly endorsed the current JCVI guidance on the extended timing between doses and our decision was based on the best available evidence at the time. It’s also important to reiterate that the evidence for groups other than cancer patients continues to suggest that the first dose of the vaccine provides a good level of protection

The KCL study is a relatively small and early study but possibly an important piece of work, nonetheless.

We have always said that we would review our position if there was new evidence and have asked the JCVI about the implications of this study on the future of the vaccine schedule.

In the meantime, please continue the brilliant work you are doing to deliver the programme according to current priorities.

We also issued this statement yesterday urging cancer patients not to be anxious - and not to contact their GP surgery to try and hasten their second dose.

Adoption and Fostering medicals

With GPs and their teams rightly focused on COVID-19 and the vaccination programme, some work has been necessarily paused - adoption and fostering medicals being a case in point in many parts of the country.

We have met with the Department for Education to discuss the challenges faced by prospective parents going through the adoption and fostering process who are only waiting for a medical before a child can be placed with them. The estimated numbers are small, but the impact on children in care is major. We will be working on a detailed statement on the safeguarding aspects of this work and hope to publish it over the next week or so to help members navigate the requirements for such assessments while the pandemic is still ongoing.

College membership for all GPs

The pandemic has emphasised the importance of recognising and supporting all frontline GPs, and we have already opened up our wide portfolio of resources free of charge to both members and non-members to support the profession at this critical time.

Now, as part of our aim to become a more inclusive organisation, we are launching a new scheme to widen access to College membership for established GPs.

Applications for the new Membership for All will open on 4 May 2021 for qualified GPs who have been on the General Medical Council’s GP register for five years and have completed either one revalidation cycle or the Certificate of Eligibility for GP Registration (CEGPR).  

Up until now, Membership by Assessment of Performance (MAP) has been the only route to professional membership for GPs who qualified or did not take the College exam prior to 2007 - when the MRCGP became the mandatory licensing examination for general practice - or for those GPs who have been internationally trained.

The need to expand the opportunity for membership to all practising GPs was supported by RCGP Council in November 2020. We hope it will enable more GPs to benefit from College membership, as well as encouraging greater participation in the College by groups that are currently under-represented.

Patient Safety Alert

This morning, we received a national patient safety alert regarding a supply of sterile infusion devices manufactured by Becton Dickinson. The problem is more likely to affect hospital trusts, but some devices are also used in primary and community care settings.

Affected stock of the following products, going back to 2016, is being recalled:

  • Infusion sets for specific Alaris Pumps
  • Gravity infusion sets and connectors

Help us influence Government

Please complete our annual tracking survey by 5 April 2021. This survey will provide the College with valuable insight into your experiences of current practice including workload, wellbeing, workforce and technology. The survey should only take 20 minutes to complete, and your response is of real value to shaping our work.

Post written by

Professor Martin Marshall, Chair of RCGP Council

Professor Martin Marshall is Chair of the Royal College of General Practitioners and a GP in Newham, East London. He is also Professor of Healthcare Improvement at UCL in the Department of Primary Care and Population Health. Previously he was Programme Director for Population Health and Primary Care at UCLPartners (2014-2019), Director of Research & Development at the Health Foundation (2007-2012), Deputy Chief Medical Officer for England and Director General in the Department of Health (2006-2007), Professor of General Practice at the University of Manchester (2000-2006) and a Harkness Fellow in Healthcare Policy. 

He is a Fellow of the Royal College of Physicians of London and of the Faculty of Public Health Medicine and was a non-executive director of the Care Quality Commission until 2012. He has advised governments in Singapore, Egypt, Canada and New Zealand, has over 230 publications in the field of quality improvement and health service redesign and his primary academic interest is in maximising the impact of research on practice. In 2005 he was awarded a CBE in the Queen’s Birthday Honours for Services to Health Care. 

A co-founder and driving force of the Rethinking Medicine movement, Martin has a passionate commitment to the values of the NHS, patient care and ensuring the GP voice is central in a time of great change. When he’s not working, he likes being outside, preferably on a mountain or a coastal path with his wife Sue and their puppy. 

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