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This paper summarises a ten-year conversation within London Journal of Primary Care (LJPC) about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. \ud COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub - both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into ‘wicked problems’ and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. \ud The conversation concludes seven aspects of COIC that warrant further attention.

The need for support for good mental health is enormous. General support for good mental health is needed for 100% of the population, and at all stages of life, from early childhood to end of life. Focused support is needed for the 17.6% of adults who have a mental disorder at any time, including those who also have a mental health problem amongst the 30% who report having a long-term condition of some kind. All sectors of society and all parts of the NHS need to play their part. Primary care cannot do this on its own. This paper describes how primary care practitioners can help stimulate such a grand alliance for health, by operating at four different levels – as individual practitioners, as organisations, as geographic clusters of organisations and as policy-makers.

Patient satisfaction is evolving into an important measure of high-quality health care and anesthesia care is no exception. Pain management is an integral part of anesthesia care and must be assessed to determine patient satisfaction; therefore, it is a measure for quality of care. One issue is how patients reflect individual experiences into their overall anesthesia experience. There is a need to identify how postoperative pain scores correlate with anesthesia patient satisfaction survey results. Postoperative pain is not a dominant measure in determining anesthesia patient satisfaction.

KEY MESSAGES We need to learn from historic changes in accident and emergency (A&E) and urgent care services and identify the conflicts in provision of planned and unplanned care. We have choices as to whom, and how, primary care services are provided in the future. But we will get this wrong if we fail to recognise that the interface between planned and unplanned care needs to be carefully managed. If managed well, we might encounter the opportunity to develop high quality, coordinated and integrated care. WHY THIS MATTERS TO ME I have watched myself and others struggle with the conflict between planned and reactive care, and thought it time to 'name the devil' in order to understand it and think about the choices ahead. Personally, I enjoy being able to deliver both planned and unplanned care to a practice population and would not want to lose either.

A form of voluntary workplace engagement, communities of practice are characterised in literature as providing entities with the potential to harness the multiplier effects of collaborative processes by building on informal networks within entities. As knowledge building and sharing institutions it would be reasonable to presume that communities of practice activities have been embraced to facilitate a level of connectedness and engagement in a university context. However, evidence from the Australian higher education environment suggests that the enlistment of communities of practice processes by universities faces a number of challenges that are peculiar to academe. We suggest that academic knowledge work practices are significantly different from the business/industry related applications of communities of practice and that an understanding of the unique aspects of such practices, together with the impediments posed by a ‘corporate university’ model, require acknowledgment before the knowledge building...

Teacher/Student engagement enriches learning experiences beyond the specifics of communicated information by encouraging connectivity and the fostering of learning communities. This paper is an analysis of student engagement in a postgraduate online-mediated learning environment, and considers how engagement may be an important factor in building communities of learning in conjunction with improved learning outcomes. This paper is informed by the conceptual framework for effective e-learning outlined by Garrison and Anderson (2003) as necessary for higher order knowledge building by students as part of skills development for participation in knowledge economies. Data collected through a pilot study infers that a correlation exists between the development of small groups of significantly contributing students within wider online student cohorts and the learning outcomes of all students within the cohort. The findings indicate that a number of small events have increased student engagement and motivation, and resulted in improved learning outcomes.

On the 1st and 2nd May 2015, participants at the RCGP London City Health Conference debated practical ways to achieve integrated care at community level. In five connected workshops, participants reviewed current work and identified ways to overcome some of the problems that had become apparent. In this paper, we summarise the conclusions of each workshop, and provide an overall comment. There are layers of complexity in community-oriented integrated care that are not apparent at first sight. The difficult thing is not persuading people that it matters, but finding ways to do it that are practical and sustainable. The dynamic and complex nature of the territory is bewildering. The expectation of silo-operating and linear thinking, and the language and models that encourage it, pervade health and social care. Comprehensive integration is possible, but the theory and practice are unfamiliar to many. Images, theories and models are needed to help people from all parts of the system to see big pictures and focused detail at the same time and oscillate between them to envision-integrated whole systems. Infrastructure needs to enable this, with coordination hubs, locality-based multidisciplinary meetings and cycles of inter-organisational improvement to nurture relationships across organisational boundaries.

RCGP London is proud of the London Journal of Primary Care. We are determined to support a transition to its next phase that should continue its high quality and increase its impact. Four years of publication have seen the success of the formula of twice-yearly themed editions. It allows the journal to print side-by-side papers that are authored by senior academics with international authority, and papers authored by local practitioners that describe grass-roots innovations. The editorial team actively seeks papers that provide a breadth of perspectives, and supports the authors to link their contributions together. This helps readers to see more of an integrated whole picture than is possible in journals that are usually constrained by papers that are spontaneously submitted. RCGP London would like this formula to be developed, to link journal papers with faculty-led educational activities. We would like teams to surround each theme, some securing and supporting the best papers, and others hosting conferences and training courses for people to learn from the themes. We want clinical commissioning groups to write up their best work for the journal, and contribute to the identification of the best themes. In this way the journal could nurture a network of practitioners and managers to explore ways to create a high quality, primary care-led NHS. This successful formula has a down-side – it is difficult to secure enough funds to facilitate the production of papers and also provide print copies. We have to face a stark decision – whether to close the print edition and compensate with enhanced e-communication, or continue with a print version which is heavily dependent on pharmaceutical sponsorship. Whichever publication choice we make, the need for engagement and involvement is paramount. Commissioning papers and generating copy is hard work! Will academic authors want to contribute to a paper with up to 40% advertising space? How will the editorial team commission enough for four publications a year? How can we help make complex issues – and articles – of interest and value to ‘jobbing’ GPs? How can members and faculty boards get involved to create educational activities around future Journal themes? How can we create and maintain interest in a web-published journal? There is no doubt in my mind that there exists the interest, enthusiasm and skills to give the journal a viable and vibrant future. How best can we make that happen? Please contribute to the faculty debate about this important decision. Tony Burch Chair RCGP London Email: moc.liamg@hcrubynot

Welcome to the fourth issue of the London Journal of Primary Care. We hope that you find this journal entertaining, instructive and useful. It is our strong belief that London deserves its own journal and that everyone should be encouraged to contribute towards it. As with all these publications the success depends on the content and readership and as readers of our journal you have the chance to influence the former by submitting and encouraging others to submit articles. You can also become involved by volunteering to be a peer reviewer. Unfortunately funding is a major issue. We would therefore value your help in approaching your PCTs to contribute £2000 sponsorship for London's only primary care journal. Also please subscribe to the journal for your practice library. We are really proud of the achievement of Paul Thomas and his editorial team and would hate to see it fail for lack of funding. This is one example of how the three London Faculties have increased their joint ventures. Our aim is to set up a London wide RCGP body so we can offer quality representation, education and support to our membership across the capital. The journal will be a vehicle for communicating our work. London boasts the highest number of trainees in the UK (not that the government or our neighbouring Deaneries are happy with this). This gives us scope to provide our AiTs with the courses and help they need to attain full membership. In conclusion we would reiterate the need for financial support and hope that you are able to help keep our excellent editorial board in business. Please contact the faculty office if you can help. Email: ku.gro.pgcr@CPJL