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Vertical Integration: you know it makes sense!
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Vertical Integration: you know it makes sense!



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  • 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
  • 3.  
  • 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%)
  • 5.  
  • 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
    • … 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