It is with great pleasure that we introduce this issue of London Journal of Primary Care (LJPC). It includes an interview with Lord Ara Darzi, Chair of the London Health Commission, about his vision for integrated care in London, alongside eight papers that build up a compelling story for change. Ara describes how fragmentation of care in London has worsened since his last LJPC interview in 2008, and now the pressures on general practice have increased considerably. Ara says that the need to develop integrated care is greater than ever, especially now that everyone is united around the shared threat of finances – the NHS has run out of money and the only realistic solution is collaborative working and smart thinking. Ara says that there must be an end to massive structural change and there is instead a need to facilitate continuous interorganisational improvements, by uniting people from different organisations and disciplines, building a shared vision, and being creative together. This approach to ‘horizontal integration’ builds trusted relationships between disciplines across organisational boundaries and needs to be part of the infrastructure of the NHS. Ara agreed that clustering general practices into ‘villages’ of about 30 000 to 50 000 population will help to do this, by facilitating collaboration in areas that are small enough to allow you to feel that you belong, but large enough to have political influence. These are called ‘health networks’ for shared primary care services, and ‘local health communities’ for collaborative health promotion. Ara also identifies a public health crisis. London has an obesity epidemic among children and there is an urgent need to support schools and parents to promote healthy eating. Public health practitioners and local authorities have a key leadership role in this, supported by health and wellbeing boards. The glaring inequalities in London also need to be a focus of urgent attention – it is not realistic to propose whole society collaboration for health improvement when there is still such a big gap between the ‘haves’ and ‘have-nots’. Primary care and public health can lead a joint approach to health care and health promotion in these new ‘health networks’, which have started forming across London. Their size and names may vary; some call them provider networks, others provider partnerships, but their purpose remains the same: to provide integrated care to their local communities. The eight papers in this issue illuminate different aspects of our challenge to help general practice take a lead role in integrated care throughout the NHS. Chellappah and Garnham's survey of medical students shows that general practice is no longer a popular career choice, but with better vision, practical ways to make it work and earlier exposure to primary care, this can be changed. We would like to see a refocus of medical student training onto health networks, so they in turn can experience the excitement and power of integrated primary care. The paper by Chana and Ahluwalia argues the importance of evaluating things that matter to patients, including personalised care, opportunities for well-being, and trusted relationships. The study by Allison et al. on patient views of the patient-centred medical home in rural Denver (Colorado, USA) echoes this view – what matters most to patients is trusted relationships with their primary care clinicians. In a second paper from Denver, Westfall et al. explore practitioners' views of the elements of the patient-centred medical home initiative that leads to accessible, coordinated, comprehensive, team-based care. In rural Colorado, there is broad-based commitment to quality, safety, outcomes, cost reduction, and patient and provider satisfaction. Bliss and While remind us that primary care is much more than doctors. Community (‘district’) nurses need to be part of extended primary care teams for integrated care, with ongoing mechanisms to build multidisciplinary team relationships. Fisher describes how participation in community development initiatives builds trusted relationships and a sense of community. These methods should be used in local health communities to stimulate local citizen engagement in health promotion and also in health networks and GP federations to bind together general practices for integrated care. The penultimate paper in this bumper pre-Christmas edition of LJPC is by Brophy and Morris. They argue that the time is right to apply all of the above thinking to create community-oriented integrated mental health services. We in RCGP London intend to actively support this proposal by setting up a think tank to consider the implications. Finally, Papanikitas relays his team's findings from the 4th annual Primary Care Ethics conference, which focused on Ethics education and lifelong learning and took in such core themes as prescriptive ethical methods, the safe assurance of status and the need to accommodate societal change.
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Oct 1, 2014
M N Pemberton + 4
Open Access
