Vertical integration: you know it makes sense!

1. Vertical integration: you know it makes sense! Dr JH Coakley MD FRCP Medical Director and Consultant in Intensive Care Medicine Homerton University Hospital NHS Foundation Trust

2. Vertical integration: you know it makes sense – well sort of Dr JH Coakley MD FRCP Medical Director and Consultant in Intensive Care Medicine Homerton University Hospital NHS Foundation Trust

4. Homerton University Hospital • University Hospital- approximately 550 beds • Emergency care predominates (70,000 to >100,000 A+E since 2003, 160,000 OPD, 35,000 IP) • Relatively young population • Income approx £140m (give or take PbR tariff fluctuating by10%)

6. Vertical integration • Primary care • Lack ambition and ability • Mercenary • Don’t like hospitals • Don’t like dealing with difficult patients, so tend to dump them in hospital • Coffee and golf

7. Vertical integration • …..so we have a few cross-cultural issues to address before we can get this to work • Assumes neat distinction between primary, secondary and tertiary care whereas it’s all rather messy

8. A few myths to dispel • Hospitals and their doctors want to keep patients in • GPs want to keep patients out of hospital • Patients necessarily want to be out of hospital

9. A few more myths to dispel • Care is cheaper out of hospital • Stripping out x% of activity will allow removal of x% of income without collapsing emergency rotas and elective work (particularly with EWTD) • FTs are predatory beasts seeking to admit patients and code them up to maximise profit, hence bankrupting PCTs/PBCs

10. Vertical integration • Our trust runs • Paediatric hospital-at-home • Continuing care of the elderly and hospital-at-home • Community maternity services including home delivery • Sexual health and community gynaecology • Community diabetes • A+E (significant primary care component) • Locomotor service

11. Vertical integration • In the pipeline • Paper clinics • Telephone, e-mail, fax advice clinics • Rapid access clinics • Hospital-at-home in other areas • Cardiology • COPD • PUCC

12. Vertical integration • PCT suggests £10m activity out • We need to increase provision clinically and financially • Do we have to stay in hospital or should we have real joint commissioning and provision? • In whose interests is it to reduce hospital attendance? • How can PCTs or PBCs commission and provide – hospital doctors do not understand this

13. Vertical integration • Finnamore (local) work • AHA / A&E and sexual health have biggest potential impact • Less so for minor procedures, ENT, gynaecology, cardiology, diabetes, COPD.

14. Vertical integration • For every change proposed, the principle question must be ‘how will this make it better for the patient, and where is the evidence to support that?’ • If we try to get it right for patients (individually and as groups) we have an outside chance of making the system work • If we just argue about money, structures, processes we almost certainly won’t • This will be difficult with present commissioning conflicts of interest • We would describe ourselves as a community hospital