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October 12, 2018
Picking up the pieces – reconciling fragmented healthcare
By: Jagdip Grewal

Medical science never ceases to amaze me – we can now treat conditions that used to kill us years ago and the march for progress continues every day, with teams of researchers, doctors and other professionals trying to find ways to treat ever more complex conditions.

This success comes with a twist though – as more people live with long-term conditions then their likelihood of having other (un)related medical conditions increases – the charmingly entitled “multiple morbidities”. This is probably one of the biggest challenges facing healthcare providers today. Despite representing just 5 percent of patients with long-term conditions (LTCs)1, these patients account for disproportionately high usage and cost of health and social care services – a situation aggravated by shortcomings in today’s fragmented health and social care models.

So, achieving the ‘triple aim’ of patient experience, health outcomes and cost reduction for patients with complex, interdependent needs lies at the heart of NHS financial sustainability.

What can be done to implement ‘Place-Based Systems of Care’? To start with, health systems must embrace a clinically-led design approach to think ‘outside the box’ and holistically identify and prioritise patient needs so that they are supported as a single ‘system as opposed to different ‘compartments’. They should coordinate services across teams, organisations and health and social care settings. Providers also need to create the right conditions for new ways of working, supported by digital solutions and information flows, if they are to maximise the benefits of the new models for patients with complex needs.

In my experience, this approach requires three critical elements:

  1. A cultural shift with providers switching from reactive care delivery to proactive coaching and prevention, scheduling bite-size encounters to address patients’ modifiable risks and needs. Care plans that incorporate clinical best practice and self-care principles can reduce service provision variability. More frequent but shorter proactive interactions alleviate the impact of LTCs, reducing the time needed for reactive care delivery and aiding the shift to more efficient service and lower usage and cost.

  2. Governance to deliver meaningful and lasting change in a complex, multi-organisation system. This requires joining the dots and creating the right conditions for multi-disciplinary care focused on patient risks and needs. At the same time, health systems must harness critical enablers such as shared vision, service configuration, incentives and an outcomes framework to translate strategy into delivery and outcomes.

  3. Patient empowerment by clinical staff proactively coaching patients to ‘Look, Track & Learn’ how lifestyle changes can improve their symptoms / vital signs, health and ultimately quality of life is also key. Harnessing digital solutions enables few clinicians to monitor and manage many patients – the biggest untapped resource – to take on more responsibility, empowered by understanding the link between their lifestyle and health. This reduces dependency on healthcare services, facilitates partnership and improves health outcomes.

In short, an approach that harnesses clinically-led design, greater patient empowerment and the right governance is needed, along with digital platforms to enable a shift to proactive care.

No one said picking up the pieces would be easy. But for patients with complex needs – and an NHS seeking financial sustainability – the rewards of solving fragmented care will be transformative. If you’re leading services for the care of patients with complex needs and would like to chat through these ideas, please feel free to get in touch.


1 Long Term Conditions Compendium of Information, Third Edition, DoH, 30 May 2012

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