Dr Judith Smith, Head of Policy at the Nuffield Trust, and Professor Chris Ham, Chief Executive of The King’s Fund, share the findings of their recent research into how NHS commissioners have been commissioning better integrated services and care for people in local areas.

1. Commissioning integrated care: what
role for clinical commissioning
groups?
Dr Judith Smith
Head of Policy, the Nuffield Trust
Professor Chris Ham
Chief Executive, The King’s Fund
20 October 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. 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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5. • 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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6. 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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7. Emerging themes – facilitators of new approaches
• Managerial leadership – senior support, drive, and risk-
taking
• Clinical leadership – as commissioners and providers –
clinicians typically the drivers of new models of care
• Data and IT – critical to contracting, tracking outcomes,
developing sophisticated payment approaches
• Provider engagement – it is costly for providers to be
involved, and a risk for them, and they will need support
• Time and persistence – takes a lot of time and resource
to plan and implement major change
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8. Policy implications – NHSCB and Monitor
• 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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9. Policy implications – clinical commissioning groups
• Developing new forms of integrated care is what is most
likely to excite and engage clinical commissioners
• 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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10. To conclude
‘commissioners who want to incentivise providers to develop
better integrated services should focus on developing
outcome measures and incentives that encourage them to
bring about these new forms of care.
This is much more likely to be successful than trying to over-
specify the details of the structures the commissioners feel
the providers should put in place.’
Ham, Smith and Eastmure, 2011, research summary report p10
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11. Download the research report & summary
www.nuffieldtrust.org.uk/publications/commissioning-integrated-care
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