Commissioning and integrated care

Dr Jennifer DixonDirectorThe Nuffield Trust

16 March 2010

Outline

1. Current context

2. Commissioning

3. Why integrated care?

4. What is integrated care?

5. What forms are evolving?

6. What is the evidence that integrated care has impact?

7. Next steps

8. In conclusion

1. Current context: some features

Financial challenge

Rising demand

System incentives misaligned

Unengaged clinicians

Weak commissioning

Avoidable ill health and costs

Current context:

Incremental efficiencies will help but..

....Change in landscape needed

A view from the US

“The current care systems cannot do the job.Trying harder will not work, changing systems of care will.”

Need systems of care in which “clinician andinstitutions… collaborate and communicate toensure appropriate exchange of information andco-ordination of care”

(Institute of Medicine, Crossing the Quality Chasm, 2001)

2. Commissioning

‘needs assessment, resource allocation, service purchasing, monitoring and review’

Objective: health

Incentives currently not aligned in system

Commissioning

History– Impact

– Small

– Transaction costs

Now– PBC limp

– PCTs: Little control over volume

New

Managerial and analytic capacity

Performance management

3. Why integrated care?

Biggest efficiency frontier:

Care of older people

Care of people with long term conditions

Avoidable emergency admissions

Rising emergency admissions

HES

Year-on-year increase

Increase against

2004/05 2004/05 4,441,224 - - 2005/06 4,666,347 5.1% 5.1% 2006/07 4,707,975 0.9% 6.0% 2007/08 4,771,541 1.4% 7.4% 2008/09 4,964,344 4.0% 11.8% NB: These numbers differ very slightly (<0.1%) from nationally published because of the method used to assign spells to years

4. What is integrated care?

Integrated care…

‘...imposes the patient’s perspective as the organising principle of service delivery and makes redundant old supply-driven models of care provision. Integrated care enables health and social care provision that is flexible, personalised, and seamless.’

(Lloyd and Wait, 2005)

Integrated organisations…

4. What is integrated care?

Types of integration I

Vertical- combination of services from different sectors into a

single organisation, perhaps across a care pathway (e.g. merged hospital and community care organisation or service)

- Payer/provider, provider

Horizontal- combination of two or more services from the same

sector into a network or organisation (e.g. joint general practice and community health care teams for people with LTCs)

Types of integration II

Internal- bringing together different

providers/commissioners within the NHS

External- bringing together different NHS

providers/commissioners with others from social care and beyond

Types of integration III

Virtual integration

- a network of collaborators

Real integration

- a single organisation

5. What forms are evolving?

Health care examples Integrated primary, community and secondary

health care

– Integrated care pilots (16) went live in April 2009

– Rooted in registered population

– Vary significantly in scale, focus and scope

– Programme expanded in February 2010

Whipps Cross and Redbridge polysystems, based around integrated health centres, and with clinical budget-holding and leadership

Trafford ICO, a whole system integration effort, including primary and community services, outpatients, office medicine/acute medicine/family medicine Possible foundation trust vehicle with

capitated budget. Development towards multispecialty ‘office

medicine’

More radical health care examples

Trafford: current service sectors

Acute provision

GP1

GP4GP2

GP3 GPn

PCT

Community services

Non-PbR services

Outpatients and

diagnostics

Inpatient, daycase, specialist

Are these demarcations necessarily helpful?

(Independent)

PCT

Formalising clinical leadership/ enhancing local control

A FOUNDATION TRUST…?

…MADE UP OF ‘MEMBERS’ ON GP LISTS…?

Community services

Non-PbR services Outpatients

and diagnostics

GP1

GP4GP2

GP3 GPn(Independent)

Consultants, GPs and nurses/ AHPs as partners?

Integrated Care Record

Inpatient, day case,

specialist

A FOUNDATION TRUST?

What forms are evolving?

Health and social care examples

Flexibilities in section 31 of the Health Act 1999:

– Lead commissioning

– Integrated provision

– Pooled budgets

Care trusts

Torbay Care Trust

Focus on care for ‘Mrs Smith’ LA social care staff TUPE’d into the NHS 5 integrated teams around groups of practices Single management of each team, with pooled

budgets Single assessment process A health and social care co-ordinator as single

point of contact

Source: ‘Only Connect: policy options for integrating health and social care’. Ham C.

More radical health and social care examples:

Adult social care commissioning and provision now transferred from LA to PCT

Public health transferred from PCT to LA

Joint health and social care teams

A single care assessor/co-ordinator with pooled budgets

Source: ‘Only Connect: policy options for integrating health and social care’. Ham C.

NE Lincolnshire Care Trust Plus

Challenges faced by these examples Time and effort required

Risk averse culture of the NHS

Stable leadership and focus

Professional and cultural change

Establishing appropriate incentives (e.g. GMS)

Making sense of integrated care within the context of other national policies

– Payment by Results

– Foundation trusts

– Competition and Co-operation Panel

6. What is the evidence that integrated care has an impact?

Limited – a lot on processes, much less on outcomes

Quite a lot from the US

More recently, evidence from other more comparable health care systems

Nuffield Trust about to commence a review of the evidence on integrated care and efficiency

Source: Ramsay A and Fulop N. King’s College, London, 2008.

7. Next steps

The General Election and subsequent policy direction

Integrating care as part of the financial challenge

New generation PBC? The potential of new forms of primary/community based providers based on medical groups

Determining how far it matters whether provision and commissioning are separate

Working out how to ensure some choice and contestability, and avoid provider monopoly

Policy barriers or enablers

PBC

How would capitation work alongside Payment by Results?

Is it time to reform the GMS and PMS contracts, to assure alignment of incentives?

How should integrated care be measured and regulated, and by whom?

Competition

8. In conclusion

Local providers and commissioners are getting on with developing new forms of integrated care

Evolution not revolution Piloting of radical examples makes sense Rigorous national evaluation is critical (cost,

quality and outcomes)