Integrated care has been defined as care that is joined up around the needs of the patient – ‘person-centred coordinated care’ [1]. It requires front-line staff to work more collaboratively with each other and the patient, often across organizational boundaries [2]. The World Health Organisation [3] defines the working definition of integrated care as:
‘the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money’.
Fourteen areas in England have been chosen by the Department of Health to pioneer new approaches to integrated care. The North West London Whole Systems Integrated Care programme is one of them. Ealing is one of eight boroughs who are trying new approaches to integrate care as part of the wider project. The most successful of these approaches will be used nationally once the programme is expanded. Educating for integrated care is recognized as essential [4] but there is surprisingly little published about its implementation [5].
The ICCESS (Imperial College Centre for Engagement and Simulation Science) team has developed the design and concept of Distributed Simulation (DS) [6]. DS is a realistic, yet portable and affordable, simulated environment that can be set up in a variety of non-clinical areas. The underlying principle is to recreate key elements of a clinical setting, rather than replicating every aspect. This drastically reduces cost and increases portability, while ensuring high levels of perceived authenticity [7]. The development of the DS tool has enabled ICCESS to explore new approaches and uses for simulation.
Traditionally, simulation has involved a single clinical encounter, whereas actual clinical care is a continuum [8]. The concept of Sequential Simulation (SqS) aims to rebuild this longitudinal characteristic of care by sampling scenes from a patient’s journey. Moreover, following the DS concept, rather than recreating every part of the patient’s pathway, SqS focuses on the representation of key ‘crunch points’ (transition of care) along the journey, encouraging reflection of the roles teams and individuals play, as well as discussions on how this can be changed or improved.
We frame SqS as the physical re-enactment of temporal aspects of care in order to:
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▪ Aid healthcare professionals and healthcare staff to visualise their role within the bigger picture (the care pathway or healthcare related scenarios)
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▪ Aid patients to understand current health system processes
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▪ Allow for critical evaluation of a current or proposed system
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▪ Test changes and new interventions within a safe environment
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▪ Open a dialogue between patients and healthcare staff outside the healthcare setting
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▪ Give patients an opportunity to voice their concerns/opinions around current/future systems
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▪ Enable co-design and co-production
Scenarios (real-life short stories, based on actual patient and clinician experiences) use actors and healthcare professionals to simulate key roles. Portable displays and props (DS) are utilised to set the scene without elaborate and expensive facilities (Fig. 1). The health professionals are therefore able to explore different ways of collaborating without endangering patients, but also gain first hand feedback on the frustrations caused to patients, users and the families from disjointed care. Once completed, the simulation can then be utilised in health education to train staff to work in a more integrated way.
Workshop design
We developed an SqS made up of a series of short scenes built up from a collection of real patient’s healthcare journey’s in the community, starting in their home and transitioning between the GP practice and the community pharmacy. This particular scenario was chosen due to the direct influence the GP receptionist had on the patient’s journey. A consensus by a range of healthcare professionals and patients around how representative this scenario was of a patient’s journey and healthcare systems was also agreed through an iterative process. GP receptionist roles are crucial in a patients care pathway, however this is not always recognized by healthcare professionals or the receptionist themselves, on the contrary, patients have a heightened awareness of it.
A Standardized Patient (professional actor) [9] was used to play the role of the patient. Real clinicians were used for the simulation*. A narrator described events that occurred in hospital and their consequences for the patient. The key scene of the SqS featured a GP receptionist (portrayed by an actual receptionist from the audience whom volunteered themselves*). The GP receptionist was briefed prior to the simulation on the conditions they were working in, e.g. no appointments left for the GP the patient is requesting to see that day. The scenes were designed to highlight the consequences of disjointed care. We also aimed to show that individuals in the pathway often act in silos, focusing on their own short interaction, without understanding the impacts of their action throughout the pathway. SqS put these interactions into context and allowed reflection on their optimization.
This SqS provided the focus for facilitated table discussions (facilitated by clinicians who took notes and guided the talks), which each included GP receptionists, patients and clinicians. The discussants suggested ways in which an unfortunate series of events could have been dealt with differently to improve the patient’s journey. These suggestions were then incorporated in a repeat SqS. The events began and ended with talks about integrated care, and what it would mean for local GP practices. Representatives from the voluntary sector or local initiatives that may assist in more integrated care also gave short presentations.
The structure of all three workshops followed the same format:
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Introduction including a presentation on whole systems integrated care
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SqS of current care in North West London
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Facilitated focus group discussions
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Large group feedback
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Co-design of ideal care SqS
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Further facilitated focus group discussions
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Concluding large group feedback
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Presentation from voluntary sector
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Expert panel.
*Please note that when using real clinicians and professionals, they should consent to and feel confident in visibly portraying their practice in front of others. They should also be made aware of the potential exposure to criticism.