The patio was perfectly laid, the slabs smooth as a baby's bum. I'd tripped over the join between one slab and the next. In management speak that would be an 'interface'; the intersection between one bit of a service (or pathway) and the next. Avoiding the joins is the Holy Grail of healthcare integration.

Looking after someone who is frail and keeping them at home creates a lot of 'interfaces'; washing, meals, tissue-viability, hairdressing, pharmacy, chiropody, cleaning, rising and twilight services, pharmacy, medicines management, shopping... the list goes on and on, complicated by the jungle of providers; Social Services, Health, private sector, voluntary sector, Uncle Tom Cobly.

We struggle with this but surprise, surprise we are not the only country that is facing the challenge of frail elderly with comorbidities, shrinking budgets and increases in demand. Most of Europe is getting older. The World Health Organisation has interesting keep-U-awake@nite data like this:

"... the population of the European Region is projected to increase only slightly by 2020 - from 894 million to 910 million - but then to return to current levels by 2050... the number of working-age people is expected to decline and the number of older people to increase... leading to an increase in the old-age dependency ratio... in particular, the number of people aged 85 and older is projected to rise from 14 million to 19 million by 2020 and to 40 million by 2050."

How do other places try to provide seamless care? Does anywhere have an answer? Well, not all countries create, like we do, an artificial demarcation between what is health and what is social care and, it's true some have no social care. Finding countries to compare with and to learn from is not quite as easy as it seems. It can be like comparing prickly-pears and hedgehogs.

One country that is similar (but much smaller than the UK) is the Netherlands. The financing and delivery of their home-care services is highly fragmented and paid for through a variety of reimbursement schemes. Their services can be uncoordinated and lumpy. They struggle with low satisfaction rates and poor continuity. Familiar?  Even more familiar will be the fact they are struggling with money, de-skilling and raising service access thresholds. Like us they're being forced into a cul-de-sac.

Reader, Doc Mike (thank you) alerted me to how the Netherlands are trying to fix it with a great concept based on neighbourhood care; Buurtzorg. They turned the whole thing on its head. Instead of sending in an army of their cheapest carers they send in highly experienced nurses trained and empowered to deliver all the care a patient might need... end2end, including the cleaning. They stripped out all the service interfaces, all the tripping points and all excess costs.

By putting their best people in the front line Buurtzog accepted a higher cost per hour of care but managed a 50% reduction in the number of hours that are needed. The clients loved it. The staff thought it was so good in 2011 Buurtzog was Dutch employer of the year.

Significantly, nurses organise their own work. Self-directing teams, of about a dozen nurses, assume responsibility for populations of 15,000 inhabitants. They become known in their communities and often leverage those relationships to find unorthodox solutions. Local overheads are minimised using central services for backup, data analysis, plus information technology; maximising nurse-2-patient facing time.

In two years 2,000 nurses joined the company working in 380 autonomous teams.  They claim clients consume 40% of the care they did previously. There is more about Buurtzog here, here and the use of the model in the US here.

Comparisons are always difficult but a couple of things struck me.  

• We have improved A&E performance by putting experienced consultants in the front line.
• GPs are learning, answering front-line telephone calls to the practice, themselves, can reduce appointment pressures.  

...we know it works.  Putting our best people into front-line care-at-home should work just as well, shouldn't it?   

It means a think-shift, training redesign and a let-go-management style but if we keep doing what we are doing we'll keep getting what we've got.

The question is; have we got what we want?