Vertical Integration: you know it makes sense!

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

Dr JH Coakley MD FRCP

Medical Director and Consultant in Intensive Care Medicine

Homerton University Hospital NHS Foundation Trust

Vertical integration: you know it Vertical integration: you know it makes sense – well sort ofmakes sense – well sort of

Dr JH Coakley MD FRCP

Medical Director and Consultant in Intensive Care Medicine

Homerton University Hospital NHS Foundation Trust

Homerton University Hospital 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%)

Vertical integrationVertical 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


• …..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

A few myths to dispelA 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

A few more myths to dispelA 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


• 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


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


• 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


• Finnamore (local) work– AHA / A&E and sexual health have biggest

potential impact– Less so for minor procedures, ENT, gynaecology,

cardiology, diabetes, COPD.


• 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

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Vertical Integration: you know it makes sense!