Introducing Volume 6 of London Journal of Primary Caer: community-oriented integrated care

The most recent edition of the London Journal of Primary Caer (LJPC) featured a paper by David Colin-Thomé and Brian Fisher on the potential of Health and Wellbeing Boards to impact positively on community health by harnessing the assets of communities.¹ They argued for the potential of this new element in the health system for strengthening social networks, increasing personal control and engaging people in service co-production – from which will come the greater community capacity needed for improving resilience and health equalities. In short, as they say, Health and Wellbeing Boards should be ‘of the people’.

Through alternate-monthly issues, LJPC Volume 6 picks up the challenge of designing healthcare systems that are of the people – that bring the dimensions of community to bear on practice for integration. This is community-oriented integrated care. Starting from an acknowledgement that community involvement has been a long-enduring feature of health policy, we bring together established ideas of what it means for integrated practice, drawing on a range of examples. We contend that although national policy is necessary to set the context for integrated care that is oriented towards local communities, how to achieve this remains contested. Nevertheless, the mechanisms to achieve this are already richly exemplified in a range of local settings.

Volume 6 of LJPC presents examples that show how the value of community life – and specifically its connectivity between active citizens – needs to be considered as the cornerstone of all integrated care. It should be the starting point for the way that all organisations responsible for integration think about their role and function, and a main mechanism to translate ideas into practice. We know that change of this kind shares the characteristic challenges of all transformations within complex systems. It requires a strategy that: (1) makes top-down and bottom-up approaches complementary, (2) develops participatory forms of leadership to enable ownership across conventional service boundaries, (3) systematically improves the capability for reflexiveness and responsiveness, (4) sets realistic timescales, and (5) makes clear at both population and individual levels who the participants in the change process are and how they can engage to share emergent learning.

Integration in this sense is necessarily complex. In the six issues of LJPC Volume 6 we look at integration practices that take complexity into account, while illuminating what is possible in very practical ways.

For example, in this issue, Mills and Swarbrick describe a social enterprise in housing in which public service ethos and mutualism can be sustained; Fisher demonstrates that patient access to records actually reduces general practice workload; and there is a neat example of how blood sugar control improved a patient's mental capacity.

In later issues, we will hear about the experience of integrated care in Quebec, Canada, which has for many years organised primary care around geographical groupings. We hear of a similar approach from New Zealand and the experience of international consultants of healthcare improvements in a number of developing countries. Elsewhere, Evans and colleagues consider integration from the viewpoint of mental health link workers; Toon and colleagues consider it within the post-admission meeting in a community hospital setting.

Our authors for this volume paint the integration argument with a broad brush. Where the now holy grail of integration seems, on occasion, to be confined to tackling the stubborn challenges of territorialism in and between organisations and their financial systems, here we present cases for an integration that moves well beyond the question of how the health and social care needs of the individual patient can be better met by a more rational service funding, to one that enables the patient's position as active citizen, by integrating services with the communities of which that citizen is a member.

Success with integration in this sense may need us to rethink fundamentally the ways in which the organisational design of our services either enables or impedes relationships that are functional and productive; Burch and Thomas, together with Easmon, consider a structural and sustainable approach to ongoing improvement and workforce development, through a practical illustration of the West London health economy.

The authors of Volume 6 offer us ways of thinking about authentic integration between healthcare and local communities, designed and delivered in a way that increasingly we term ‘co-productive’. This a theme to which we will return as we consider approaches such as that of ‘connected communities’, in which local interventions for inclusion and wellbeing are developed, guided by a mix of deliberative community engagement (involving community members as researchers) and social network mapping to depict social and community network connection.

Taking into account the current public funding crisis, we regard the case for models that harness community resources as clear and compelling. An integration that sees communities as a central part of its whole-system approach will raise challenges to commissioning and delivering services that are both general and familiar – management of risk and confidentiality, for example. It will, however, also highlight specific challenges: How do we develop leadership teams that are capable of facilitating complex community collaborations, as has been highlighted by Kelly-Patterson,² and how can structures such as the West London ‘integrated care pilot’ discussed in LJPC Volume 5 be adapted to develop such leaders?

These and more questions will be explored through an international network of case studies of communityoriented integrated care. This is not easy territory and we need a broad range of people to contribute their insights. We need your insights – so please get involved.