1. Commissioning integrated care:
insights from our research
Dr Judith Smith
Head of Policy, the Nuffield Trust
Professor Chris Ham
Chief Executive, the King’s Fund
22 September 2011
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2. Agenda
• The research project
• Case studies of commissioning integrated care
• Emerging themes
• Policy implications
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3. The research project
Project aim
• To understand how NHS commissioners were using their
leverage to develop more integrated care
• To examine the extent to which such attempts were
focused on efficiency, as well as service quality
• To consider what this means for commissioning in
economic hard times, and in the new reform context
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4. The research project (2)
Project approach
• A questionnaire survey of all PCTs in October-November
2009, seeking information about innovations in
commissioning
• A survey by email and phone of SHA commissioning leads
• Approaches to national organisations
• Use of an expert advisory group
• Review of US literature on payment reform
• Case studies of innovative examples of commissioning,
developed via research visits and interviews, and review of
documents © Nuffield Trust

5. The research project (3)
What we thought we might find
• Commissioning care pathways rather then episodes of care via
Payment by Results
• Commissioners working with lead providers to promote
integration, and the use of subcontracting by these lead providers
• New forms of payment to incentivise integration, such as
payments for care pathways and other forms of payment bundling
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6. The research project (4)
What we found
• PCT survey had a disappointing response, despite a follow-
up chaser
• Survey of SHAs, and discussions with advisory group and
national organisations added some examples
• Overall, most examples were provider-initiated, and it was
difficult to find ones that were led actively by commissioners
• We drew up a long list of examples, from which a number of
case studies were selected
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7. Case studies of commissioning integrated care
• Birmingham North and East PCT – commissioning
integrated care for people nearing the end of life
• Milton Keynes PCT – seeking to contract an ‘accountable
care organisation’ for a whole programme of care
• Tower Hamlets PCT – commissioning outcome-based
diabetes care from networks of providers
• Smethwick Pathfinder – a group of GP practices holding
a capitated budget for managing the care of people with
long-term conditions
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8. Case studies of commissioning integrated care
• Cumbria PCT and practice-based commissioning –
commissioning integrated diabetes care across a county,
using a new specialist care organisation
• Knowsley PCT – contracting with a lead specialist
provider to deliver the full range of cardiovascular care for
a population with major health inequalities
• Somerset PCT – commissioning an integrated COPD
service from a partnership of BUPA and a company
formed of local GPs
• West Kent PCT – commissioning a social enterprise to
deliver integrated out-of-hours primary care and
emergency primary care, based in the hospital A&E
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9. Emerging themes – the cycle of commissioning
• Needs assessment and service specification – took up
considerable time and resource, helped with engagement,
but hard to move to implementation
• Contracts – a range of mechanisms used, including PMS,
GMS and adaptations of PbR and acute contracts. Seems
there is more potential to use existing mechanisms
• Tendering and procurement – costs of this were
prohibitively expensive in some cases, yet others were
able to contract for new forms of care across organisations
• Outcomes and incentives – the value to be had from
linking payment to expected outcomes, and doing this in a
phased manner
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10. Emerging themes – facilitators of new approaches
• Managerial leadership – senior support, drive, and risk-
taking
• Clinical leadership – as commissioners and providers
• Primary care-led commissioning – PBC as a catalyst for
service review, redesign, and change
• Data and IT – critical to contracting, tracking outcomes,
developing sophisticated payment approaches
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11. Emerging themes – facilitators of new approaches (2)
• The registered list of patients – important for population-
based approaches and budget-holding
• Provider engagement – it is costly for providers to be
involved, and a risk for them
• Time and persistence – takes a lot of time and resource
to plan and implement major change
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12. Policy implications
• Central support for commissioning of integrated care is
vital
• The role of Monitor will need to be crafted in a way that
promotes both competition and integration
• There is a need for further and more extended
experimentation with tariff and incentives for integrated
care
• A range of approaches to contracting and procurement will
be needed
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13. Policy implications (2)
• Some GP commissioners will want to be able to ‘make’ as
well as ‘buy’, and policy on conflicts of interest will need to
address this
• There is a need to think again about how the
commissioner-provider split might operate in future,
perhaps testing out new integrated provider-funder
organisations
• In whatever approach, aligning incentives across primary
and secondary care, and also social care, will be vital
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14. To conclude
‘ The balance of risks and incentives placed on
commissioners and providers in the NHS appears at
present to be wrong. Commissioners seek to develop
more population-focused and preventative approaches to
care [...] yet providers remain incentivised to increase
activity and expand services within their organisation.
Perhaps the strongest message from this research is that
PCTs have struggled to put providers sufficiently at risk in
relation to developing better integrated and more efficient
care.’
Ham, Smith and Eastmure, 2011, p35
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