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Integrated care organisations and their vital PBC role

The announcement this month of the final 16 integrated care pilots has put ICOs in the limelight - but ICOs are about more than the pilots, as Dr Oliver Bernath explains.

The announcement this month of the final 16 integrated care pilots has put ICOs in the limelight - but ICOs are about more than the pilots, as Dr Oliver Bernath explains.

1. Define an ICO for me

Well, the first thing to stress is that being an integrated care pilot does not mean you are actually an integrated care organisation.

The DH integrated care prospectus was very relaxed about the criteria for what could be an integrated care pilot – the pilots had to be based on a registered patient list and have the local PCT's approval.

The prospectus talked of teams of primary and secondary care clinicians, or health and social care professionals who might be based in the same place or employed by the same organisation and also said integration might possibly involve bringing together resources. Again it was non-specific on the means to pool resources but said this could include delegation to providers of a risk-adjusted capitation sum for a group of registered patients. This would be an integrated care organisation.

Looking at the scope of the newly announced national pilots, I would say they only address narrow slivers of the totality of care – urgent care, elective care, community care, prescribing, primary care. But none of the pilots seems to cover the whole spectrum of care.

2 Do you need integrated care organisations then?

My view is that you need to go for the whole lot – one service, one team, one budget to strengthen the whole patient focus, otherwise we end up with the balloon problem.... squeeze it in one place, only to see the problem pop up elsewhere. We want to have the whole balloon in our hands so that we cannot shift a problem from one area into the other – if we do, inadvertently, we still have to live with the consequences.

So, to me an integrated care organisation is a provider organisation that takes on the PBC budget together with GPs but has a real contractual obligation – the ICO takes on a capitated delegated sum at risk and delivers to the commissioner whatever outcomes and services they want to see. It helps providers to organise themselves without needing to become employees of one company. This way GPs can stay as independent practices.

GPs are the lynchpin of all this as they hold the patient list and have a gatekeeper function for the whole healthcare market.

ICOs have a total pathway view. For example, at the moment a GP knows what care an asthma patient receives in their practice, the hospital knows what care the patient receives with them, but nowhere is it all pulled together and that makes it difficult to see which points of that patient's care need improvement.

As well as the management capability, ICOs would also provide the analytic capability to map and track entire care pathways with all costs and benefits – both outcomes and patient experience. This can become quite IT-heavy as you need information systems that can enable that analysis not only a year in retrospect but also at the time something like an admission happens.

ICOs would also provide capital, first to buy equipment but also to provide underwriting cover for the overspend risk that is too large for a GP practice to carry.

3 Where has this concept come from?

This type of organisation has not been seen before in the UK, but the need comes from both clinicians and patients.

As a consultant neurologist I felt great frustration receiving referrals where, if I had been involved earlier, I could have prevented half the complications, and when I sent the patient back to the GP I had no further influence. It was an isolated care episode rather than a longitudinal one.

GPs have the same frustrations – it takes a long time to access a consultant's expertise, the outpatient appointment often takes a long time to come through, then after the consultant has seen the patient the GP gets a letter back that may not address what they felt the problem was. The patient has to navigate the whole healthcare system themselves as they are the only person who sees the whole picture.

The current fragmented system doesn't really work for patients – when unnecessary complications arise, it is bad for patients and is a drain on healthcare resources.

PBC is a start but it is just the first step of a longer journey. There is not enough transparency around how the budget numbers come together so GPs don't know how to influence it. Nor do GPs really have the freedom, tools or power to shape it. As

a result it has caused a lot of frustration. ICOs are the next step for PBC, though the need for practices to be like-minded is far greater than geography. The practices involved need to be high-performing and innovative to take this on. There is also scope for the ICO to contain practices from different consortiums and for some practices in the consortium to stay outside the ICO.

4 Why should commissioners be interested when there are so few ICO pilots?

We have started our own pilot outside the national programme with a wide range of initiatives covering the whole range of care. This can be done under the existing PBC

set-up if your PCT is willing. The national pilot programme prepares policy development but it doesn't stop anyone else from going it alone. We felt we could get more quickly from the pilot stage into the proper ICO stage by going it alone.

5 Why is the patient list so central to ICOs?

If you were to allow a provider to select their patients, they could cherry-pick the young healthy ones and pass those with chronic conditions back to the NHS. The NHS would be stuck with the high-cost population.

Also, if you had specialist providers for different disease categories – for example a specialist organisation for diabetes care – you would be taking apart what primary care is trying to pull together. The commissioner would be paying the GP a fixed amount per registered patient and also paying the specialist provider for diabetes care, so would either be paying twice or would take the money for diabetes care away from the GP.

If the same approach is taken with other conditions you eventually disaggregate the whole primary care package. Then you have no need for a GP and end up in the situation where the patient is looked after by all these specialist providers and nobody looks after the whole patient any more. Also, it would be impossible to allocate a budget if you didn't have a population base to base it on.

6 What about the provider- commissioner conflict? ICOs seem to blur lines even further.

When a GP sends the patient to a cardiologist are they subcontracting a piece of care or commissioning? This is where the grey zone is but it already exists and is inextricably linked to the job of the GP.

The conflict arises if the GP has a financial interest in influencing patient choice. It may be that the GP's relationship with the cardiologist is actually good for patient care but the conflict of interest would have to be declared and the profits mitigated.

In my vision, first there has to be full transparency. If the practice has its own cardiologist, it has to tell the patient the appointment might be faster but it has to declare the relationship with the cardiologist.

Second, if provider organisations are not-for-profit community interest corporations where the service gets paid for fairly but there is no additional profit, then the financial interest is just one of providing the best service at the cheapest cost and there is no conflict.

7 Do practice-based commissioners have a choice not to get on the ICO train? What will happen if they don't?

ICOs will have to prove they are not underspending on patient care to maximise profit and that patients will receive at least as good care, if not better, than they would elsewhere.

GP practices that don't like being scrutinised are not suited to being part of an ICO. However, I feel most practices that are proactive and proud of what they do will sooner or later join the ICO bandwagon. The practices left behind will probably be the ones that don't want to engage, or whose GPs are close to retirement or afraid that their standards are not as high as the ICO would demand.

Then the challenge from the PCT's perspective is to examine how to motivate those practices and what consequences the underperforming practices would have to face. The failings of some practices, which have always been there, will become more obvious.

8 What will happen if we have a change of Government? The Conservatives seem cold on ICOs because of the commissioner/provider split.

Andrew Lansley has said he thinks it is not necessary to create new organisations. In a sense I agree. We do not need something to replace GP practices or hospitals, you do not need a new provider organisation, but you still need a different level of management that understands the total care of the patient across the different providers, and something to help with the systems integration and to make the information flow better, and somebody to take on the financial risks.

Dr Oliver Bernath is managing director of Integrated Health Partners
Interview by Miranda Griffin

The integrated care pilots selected by the department of health

Bournemouth and Poole Teaching PCT
Collaboration between GPs, public sector organisations and third-sector services to explore a new model for delivering care for older people with dementia, which will include a single point of access to an integrated community team.

Cambridge Assura LLP
Pilot to look at how different organisations across the health, social care and third sectors can better communicate and co-ordinate end-of-life care to enable people to be cared for and die in the place they choose.

Church View Medical Practice
Local acute trust and GP practice to work together as an integrated organisation, in partnership with the PCT provider arm, social services and the patient practice group to improve quality of care and experience of services for the area's population of older people. Has a focus on management of long-term conditions.

NHS Cumbria
Collaboration between GPs and patients to explore a new approach to helping patients with chronic diseases manage their own care.

Durham Dales Integrated Care Organisation
Seven partner organisations working together to meet the needs of a rural population, provide continuity of care and reduce health inequalities by exploring a number of different care pathways.

Nene Commissioning CIC
Development of new models of long-term condition management to help patients remain independent for longer and have more choice in their end-of-life care.

Newcastle Hospitals NHS Foundation Trust
Development of community services via a network of community-centred training services led by clinicians, in partnership with the third sector and other agencies, with the aim of preventing falls in over-60s.

Cornwall & Isles of Scilly PCT
Case managers to improve dementia diagnosis and care by uniting primary, secondary, health and social care services.

NHS Norfolk and Norfolk County Council
Integrating care services for the elderly through joint working between the PCT and local authority that will develop personalised care plans.

Northumbria Health Care NHS Foundation Trust
COPD self-care pilot with providers working together to co-ordinate care and provide consistent information and education to patients.

North Cornwall Practice-Based Commissioning Group
10 GP practices working together to integrate mental health community teams and to integrate with mental health acute
and social services.

Principia – Partners in Health
Identification of at-risk COPD patients through partnership working and development of improved clinical pathway to integrate care.

NHS Tameside & Glossop
Development of partnerships to change behaviour of people at risk of CVD.


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