The effective integration of health and social care has been a long-term ambition for many governments. However, it has been a challenge to create systems that can effectively join hospital-based treatment and community care to reduce the growing burden of preventable illness. This is because we have payment systems that create unintended and perverse incentives.
Hospitals will always need income for expensive and curative treatments and care that they provide, but there is increasing and unsustainable pressure on hospital-based care. This means that new relationships around better and more proactive community care are needed to help keep populations healthy and better able to better manage their own health conditions. Connected, comprehensive and accurate data will help to promote early intervention and improve patient health literacy for recovery and rehabilitation. It will also ensure we invest in measures that enable healthier lifestyles, that build resilience against further illness which is expensive to the patient and the health and care system.
Risk stratification plus will help to reduce avoidable illness and system pressures
Integrated data can highlight those individuals and groups of people who are at most risk of experiencing ill health. This risk stratification means bringing together connected data from the hospital, primary care, community services, social care and mental health to reveal the impact a person’s health has had and risk of future impact on the system as a whole.
To move into a future where systems are working together, identifying patients with high usage of services that would benefit from more targeted care through population health management, will rely on access to such data from primary care and community services and not just HES data that can only reflect the billable services a patient has used.
Our starting point for reducing illness and improving health, must be the community where the complex pathology originates and not the hospital where it may end up. Using data collected from episodes of care and contact within the community and hospital, a picture will emerge of a patient’s usage of the whole health system, which can then be used to predict likelihood of usage in the future. Details about lifestyle, environment, work and genetics will also help to identify those who are at the highest risk of getting ill or who could risk current conditions being exacerbated.
Combining different types of data, that are already in existence, such as in social care, will help add the richness needed to give an overview of highly complex and nuanced health and care needs within our communities. However, NHS data does not currently align itself seamlessly with that of social care.
Integrated care systems (ICSs) give us the opportunity to view and operate healthcare across the whole spectrum, sharing connected data that gives greater focus to the steps that are needed to improve health and reduce illness. The opportunity with the new ICSs means we can ask new questions and find answers to problems that can only have an integrated whole system solution. It is only by curating and sharing this rich data seam that we can develop new ways of improving wellness, create self-healing communities, reduce the burden of illness and help the health and care systems be effective, efficient and sustainable.