2. 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
3. 1. Current context: some features
Financial challenge
Rising demand
System incentives misaligned
Unengaged clinicians
Weak commissioning
Avoidable ill health and costs
5. 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)
6. 2. Commissioning
‘needs assessment, resource allocation,
service purchasing, monitoring and review’
Objective: health
Incentives currently not aligned in system
7. Commissioning
History
– Impact
– Small
– Transaction costs
Now
– PBC limp
– PCTs:
Little control over volume
New
Managerial and analytic capacity
Performance management
8. 3. Why integrated care?
Biggest efficiency frontier:
Care of older people
Care of people with long term conditions
Avoidable emergency admissions
9. 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
11. 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…
12. 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)
13. 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
14. Types of integration III
Virtual integration
- a network of collaborators
Real integration
- a single organisation
15. 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
16. 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’
17. 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?
18. 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…?
19. 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
20. More radical health and social care
examples:
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.
21. 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.
22. 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
23. 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.
24. 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
25. 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
26. 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)