In the English NHS, we know from past research that it is typically providers of health and social care who initiate new forms of integrated care. However commissioners have also made important contributions.
A 2010 report by the Nuffield Trust reviewed five areas in England where commissioners had worked to attain closer integration at a scale and pace. Two later studies released in 2011, Commissioning Integrated Care in a liberated NHS and Towards integrated care in Trafford go further, describing how NHS have commissioners used their leverage to develop services, in partnership with providers, that were better integrated for patients.
In this article we present three case studies of NHS commissioners featured in these research projects. Separately and together they highlight factors critical to the successful commissioning of integrated care – imaginative contracting, IT and analytics and relationships.
Case study 1 (Contracting): Tower Hamlets – commissioning with networks of GP practices
Although they offer an apparently powerful mechanism through which funders can lever change, Tower Hamlets is one of the few places where commissioners appear to have used primary care contracts to commission significantly different forms of integrated care.
Approximately three years ago, a benchmarking study indicated that the local PCT had consistently underinvested in primary care. The PCT responded with an increased recurrent investment in primary care worth approximately £6million. Inevitably the decision raised questions about whether more could be done to strengthen the way primary care services were commissioned to improve performance, and ensure that the new investment would guarantee the required changes to local services and patient outcomes.
A strategic decision was taken to create networks of GP practices that could act as the building blocks for increased investment in primary care. The scaling up from practices to networks was important, as it allowed networks of practices to share resources and specialist staff, for example in delivering new forms of specialist and community-based diabetes care. The model also provided a sound basis for review of use of the estate, development of extra services, and a forum for increased peer review among practices.
The overall purpose of the practice networks in Tower Hamlets is to introduce new forms of integrated clinical care, the first of which has focused on diabetes. This was chosen because of high local prevalence and need, as well as the strong clinical evidence base for diabetes management.
Three specific objectives were set: decreasing the geographic variation in the delivery of care across local practices; getting the right person, into the right place, and doing the right things at the right time; and using secondary care more appropriately.
A contract was devised between the PCT and the practice networks, rather than with individual practices as would usually be the case in the NHS. Parallel contracts with local community health and specialist services were run alongside these, with the overall mix of contracts adding up to the integrated care pathway.
When the networks were first set up they were the only part of the system to hold risk-based contracts – thirty percent of the contract value being contingent on the network of practices (that is all of them as a collective, with pressure on the practices to ensure they all perform) achieving a set of overall diabetes outcomes indicators, which include patient experience, care planning and delivering stratification data. Over time, the percentage of payment dependent on meeting specified outcomes will increase.
This arguably creates an incentive for practices to exert extra pressure on community diabetologists, community nursing, and allied health professional staff to play their part in enabling overall achievement of population health outcome targets.
Case Study 2 (IT and analytics): PHD – primary care led commissioning of population health
Pathfinder Healthcare Developments (PHD) is a community interest company (it reinvests any surpluses it makes for the good of the community), owned by the GPs who operate Smethwick Medical Centre in the West Midlands.
Inspired by the potential of practice-based commissioning, the Smethwick GPs and their teams wanted to go beyond what was possible through holding an indicative budget for health services planning and negotiated with the local PCT to hold a real budget for their registered practice list of patients.
This gives them license to put into place a much more proactive approach to the management of health and the avoidance of illness, based on analysis of the patient population, identification of people at risk of illness, and the crafting of preventative care to help keep them well and avoid admission to hospital.
PHD’s population-based approach now spans a range of services and conditions, including the care and case management of people living with long-term conditions; illness prevention; elderly care; community nursing; anticoagulation, orthopeadics; diabetes pain relief and a service for asylum seekers.
The registered list has proven key to the work of developing a proactive approach to care management, as well as forming the basis for the allocation of capitated budget. Using the registered list as a foundation, PHD has also built a new integrated patient record that includes:
· Information about attendances at NHS services
· Details of health status and risk of ill health
· Planned screening and observations
· Triggers for the individual to be invited to attend for tests and treatment
This is in stark contrast to so much of NHS commissioning which is concerned with the provision of services in a largely reactive and episodic manner. Clinical commissioning groups will arguably be in an unrivalled position to use the registered list as the basis for commissioning for population health management, in the way that Smethwick has demonstrated.
However it is important to note that Smethwick received considerable in-kind support and advice for the management of their registered list and related IT developments through their partnership with health insurers Aetna. The challenge for CCGs will be to secure similar levels of management, analytical and development support at a time of constrained funding for NHS administration and management.
Case Study 3 (persistence): NHS Trafford
A consistent finding from research into commissioner-led integration has been the vital importance of getting the relationships right from the start as a way of dealing with obstacles. Trafford, where NHS organisations have been working for more than three years to develop integrated care demonstrates this clearly.
What emerged in Trafford was a plan to develop much closer collaboration between community-based primary, general acute medicine, specialist outpatient and diagnostic care.
In April 2010, the PCT agreed to fund a ‘proof of concept’ year, providing £2 million of investment funding to support initial implementation and lay the foundations for more extensive integrated care across the Trafford area. This initial implementation involved nine ‘vanguard’ general practices working with community, acute and social care to redesign selected care pathways, share data, identify patients at risk of unplanned hospitalisation, and generally to act as a test bed for implementing and evaluating integrated care.
The focus was not only on creating an integrated care trust, but also on redesigning services across the health economy on the basis of integrated models of care.
To achieve this level of change, seven work streams were planned to: enable engagement of clinicians, managers and patients in a process of continuous quality improvement; reshape clinical teams to support delivery of integrated care; and better target health care through real-time data-sharing and improved use of the GP list.
The aim was to establish an integrated care trust by October 2010. To do this, approval for the plans was needed from the cooperation and competition panel (CCP). The CCP recommended that the plans for the Trafford integrated care trust underwent ‘full’ rather than ‘fast track’ review.
By November 2010 the SHA had also announced that it was not confident that the proposed integrated care trust could make either the efficiency savings required, or help to reduce the deficit at Trafford Healthcare NHS Trust at the necessary pace, without significantly affecting the quality of patient care.
In light of these changes, the approach to integrating care in Trafford has shifted to focus on making a series of careful investments to increase collaboration across the health care system and change the way that existing functions work.
The Trafford experience has shown that the nature and quality of professional relationships is as important to developing integrated care as robust business and financial planning. A key to this has been to nurture informal contact (such as practice visits and social events), as well as the more formal committee-type interactions (such as clinical panels).
Fundamental to developing this culture has been the cultivation of clinical leaders. This has entailed formal appointments to substantive managerial posts (such as a consultant geriatrician being appointed as medical director within the acute trust) or through, for example, chairing committees (including the Clinical Board or clinical panels) and leading the work of vanguard practices.
Many GPs have been active, for instance, as leaders in practice based commissioning groups or the shadow GP clinical commissioning group, and three GPs have been appointed as locality medical directors within the local acute trust. Other GPs have been much less involved and have focused on, for instance, ongoing participation in Clinical Congresses and attendance at practice-based commissioning meetings. This differential level of involvement in the early stages was not considered to be a problem so long as GP opinion-formers were actively engaged and able to communicate progress clearly to other GPs. As noted above, nine vanguard practices – where the new integrated approach is being developed – were identified during the ‘proof of concept’ year, and the GP leaders supported.
Commissioners keen to pursue a similar route to integration would do well to focus less on the details of structures and processes within providers, and more on crafting an environment where providers are at both risk for, and incentivised to, develop the necessary processes to deliver high quality care for a particular population.
Moving forward the question now for GPs is whether they can make more of the levers inherent in the commissioning or ‘paymaster’ role than PCTs did, while also exploiting the potential this new organisational form offers. These include the greater scope for establishing clinical consensus across the primary/secondary care divide, and due to the ‘make and buy’ possibilities, the option of developing with acute and community providers new service models that distribute risk and responsibility differently.
Ham C and Smith J (2010) Removing the Policy Barriers to Integrated Care in England. London: Nuffield Trust.
Ham C, Smith J and Eastmure E (2011) Commissioning Integrated Care in a liberated NHS. London: Nuffield Trust
Shaw S and Levenson R (2011) Towards Integrated Care in Trafford. London: Nuffield Trust