Dr Jennifer Dixon: Commissioning and integrated care
Commissioning and integrated careDr Jennifer DixonDirectorThe Nuffield Trust 16 March 2010
Outline1. Current context2. Commissioning3. 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 steps8. 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 and institutions… collaborate and communicate to ensure appropriate exchange of information and co-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 Year- Increase HES on-year against increase 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…
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
More radical health care examples 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’
Trafford: current service sectors PCT Acute provision PCT Inpatient, Community Non-PbR daycase, services services specialist Outpatients and diagnostics (Independent)GP1 GP3 GPn GP2 GP4 Are these demarcations necessarily helpful?
Formalising clinical leadership/enhancing local control A FOUNDATION TRUST? A FOUNDATION TRUST…? Consultants, GPs and nurses/ AHPs as partners? Non-PbR Inpatient, day Community services Outpatients case, services and specialist diagnostics Integrated Care Record (Independent) GP1 GP3 GPn GP2 GP4 …MADE UP OF ‘MEMBERS’ ON GP LISTS…?
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
More radical health and social careexamples: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 contactSource: ‘Only Connect: policy options for integrating health and social care’.Ham C.
NE Lincolnshire Care Trust Plus 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.
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 integratedcare 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)