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Through the looking glass of integrated care

Hard-wired GP

Luke Koupparis

Monday, 30 December 2019

AdobeStock_208659881_integration.jpgAs a child I recall reading the novel by Lewis Carroll called Alice Through the Looking Glass where she enters a fantastical world by climbing through a mirror. It was the sequel to Alice’s adventures in Wonderland, in which she enters yet another alternative reality based upon a game of chess, but with talking pieces. When in this magic world she finds that everything is reversed, including logic where running makes you standstill.

Recently, I am starting to worry that I have climbed through into a new NHS sphere where everything is about integration, only it doesn’t quite fit together as to how it will work in practice.

There seems to be so many levels that I, as a GP, should be amalgamating with other organisations at the moment. NHS England has given me a plan outlining that integration can occur at the System level (ICS), Place (ICP) or the neighbourhood (PCN). Just when I was starting to get my head around Sustainability and Transformation Plans, these have metamorphosed into Integrated care Systems and this change is anticipated to merely accelerate the work already completed. However, I am not completely sure what the STPs have done yet if I am honest.  

The rebirth of the working together agenda is the yet another political panacea to solving all the budgetary and workforce demands that the NHS faces. Winter has taken us by surprise for another year and we are receiving emails that the Operational Pressure Escalation Levels (OPEL) are off the scale and to stop referring (sick) patients into the shiny hospital.

ICSs are heralded to provide a solution to busy hospitals by clearing them out of patients. They will do this by converting complex health landscapes into one system, with healthcare leaders in the room together deciding how to work together as a single entity thereby magically freeing up resources.

NHS England is clear that every part of the country should be an integrated care system by 2021 and by joining up we will be able to deliver well-coordinated efficient services to patients who need them.

One example of what might be provided in this new integrated world is that for complex patients who regularly use different services to feel like they are dealing with one team who make time to understand the full health or care needs.

However, I keep hearing that we need to keep people out of hospitals and in the community. Hospitals are funded to see patients via a tariff, volume-based system and this model is just costing far too much money. All the work that the integrated care system will deliver will serve to move these patients into all-you-can-eat buffet style block contracts sitting within the community.

Budgets will be allocated/devolved to these integrated units thereby making the system accountable for any overspend. NHS England will hold these systems to account should they not deliver on said objectives or financial savings.

What does this really mean?

Thus far it has not been possible to address the issue where more and more patients are attending hospitals for treatment. Clinical commissioning groups have not managed to quell the money flowing into the secondary care business model. Therefore, in order to deal with this difficult financial issue, the hot-potato has been passed to community providers under the guise of integration and hey-presto all be sorted. I can’t help thinking that this is just a classic hospital-pass delivered to yet another new “system” but just a little further from the centre. A system set up to fail with the only possibility of success beholden on the staff working harder within the same budgetary constraints.

There are frequently assurances that if money is taken out of secondary care, then the community will have a greater investment to deal with this increased workload. Continuing the Alice theme this reminds me of when the White Queen is trying to induce Alice to work for her, “jam to-morrow and jam yesterday – but never jam to-day”. Even, as when Alice objects that “it must come sometimes to jam-today” the Queen’s answer is always “it's jam every other day: to-day isn't any other day, you know”.

Instead, maybe the solution to this new integrated care system is simple, we just need to wait for hordes of talking pawns to appear to provide care for less and less patient numbers every day. It might just be the solution to stay in the magical world beyond the mirror.


  1. Carroll L, 1871. Through the looking glass.
  2. Integrated care systems. NHS England.

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Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group, LMC representative and chair of the locality provider group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist and likes to ski with his children.
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