Integrated care – is it the beginning or the end for PBC?
Pulse | Practical Commissioning | 26 June 2008
With the forthcoming Darzi review set to contain much about integrated care, Professor Chris Ham explains more about the concept and what the PBC opportunities are
What is integrated care?
It’s about patients getting care that is co-ordinated when they use the NHS.
Often people look at the NHS and say it’s wonderful because it’s a publicly funded health service and has a primary and secondary care system.
On the face of it, the NHS looks as if it has an integrated care system, but when you open the door and look inside you often find that GPs, hospital consultants and nursing staff are working in silos.
Patients might have good care from their GP or in a particular hospital but the links between primary and secondary care could be improved.
Is it the same as managed care?
Managed care is what happened in the US 15 years ago. It got a bad name because it restricted patient choice and clinical freedom, leading to a backlash.
You have to be a bit careful in using the term managed care here because it can be argued that a lot of care has already been planned here since the inception of the NHS and we start from a quite different position.
An integrated care system of clinically managed care is about giving doctors and nurses much more control over how budgets are spent.
It’s important to make the distinction between clinically integrated care and vertically integrated care. Getting clinicians working together is much more important than vertical integration, which requires organisational change. For example, in Scotland they have health boards that are responsible for the full range of care.
My view is that although that might be beneficial, the main point we want to start from is to get hospital clinicians and GP practices working much more together.
Eventually that might end up requiring an element of organisational change but that shouldn’t be the starting point.
Why do we keep hearing this term at the moment?
A lot of people are recognising integrated care has many desirable features. If you look at the problems we are trying to solve in healthcare, we are faced with an ageing population so the burden is shifting away from acute life-threatening conditions to long-term chronic conditions that require both primary and secondary care support.
A GP faced with a patient with complex needs should be able to get access to a specialist nurse or consultant opinion very quickly. Integrated care is the best way to meet the needs of the changing population.
The Darzi review has been looking at integrated care and early reports have been positive about it. A lot still rests on the final report due out next month to set out how it’s going to be developed and supported.
What tools do we need to make integrated care happen?
Some of the payment and incentive systems in the NHS need to be looked at. Many of these work against integrated care at the moment. Payment by Results creates incentives for more hospital activity.
PBC creates incentives to provide more services in the community but doesn’t necessarily encourage closer integration with hospitals.
The QOF has raised standards in primary care but again not addressed integration.
Then there are penalties for local authorities that can’t provide care in the community when a patient is ready to leave hospital.
So there are some quite strong incentives in the NHS but none is designed to support closer integration. The Government needs to think about how the money currently flows around.
If you start with PBC it might mean that where GPs have shown that they are able to take on budgets for commissioning, the Government needs to allow them to take that as far as they can.
This means budgets on a sufficiently large scale so that it makes sense for specialists who work outside the hospital to work with these practices.
To make this clinically and financially viable it needs to be made much more worthwhile because the incentives at the moment are not strong enough.
Will polyclinics feature strongly in integrated care?
They might be part of more integrated care but it depends on which area you are in.
The problem with polyclinics is they’ve been presented as a national solution that Lord Darzi wants to apply universally.
In London you could argue primary care has not been as well developed as in other parts of the country, so in London there is a need for a new model that brings together practices, diagnostic facilities and other services.
This might take the pressure off overstretched hospitals. Elsewhere, polyclinics are likely to be less desirable.
What’s the vision for integrated care?
You have to start from a patient point of view and ask what patients need from a high-performing healthcare system.
When patients come into contact with the NHS, they should have accessible and responsive care with minimal waiting times and care provided by doctors and nurses using up-to-date evidence-based medicine.
It’s an overused word but seamless care is what integration is about: care that doesn’t have gaps that the patient or their family currently have to try to join up.
It means overcoming very deep and historical divisions in British medicine.
With chronic diseases you need a model where specialists work very closely with GPs and you don’t have organisational or professional separation. There will need to be much better liaison between GPs and specialists to make sure patients get a high-quality and responsive service.
Too often we end up with a service where patients, carers and family members have to co-ordinate a system that is not very well integrated or co-ordinated.
Is any one model of integrated care better than others?
In a recent Nuffield Trust report I described three different models (see box below).
We don’t really have much evidence one is better than the other and the point the report was trying to make was that there was no single model people should follow.
It depends on local circumstances.
If you’ve got well-organised primary care services with the engagement of GPs in PBC it’s more likely that the Epsom model will become a reality.
Where primary care is not so strong but you’ve got a really well-run hospital, then the Birmingham model is more promising. For other areas the Bolton model may be the route to take. In some places the three models and others might coexist.
We probably need a pilot programme to test the models that exist in the future.
Are GPs in a strong position to take on integrated care?
To get to the nitty gritty of this, integrated care is about identifying priorities locally.
If there’s scope to improve a service – say, diabetes – then the starting point is to look at how this service works so that the hospital-based specialists can start to work with GP practices. From a specialist point of view it makes more sense to do this with a number of practices rather than just one.
The point is clinicians have got to sit down together and work this through.
If you’ve got a good PBC consortium already, there would be a platform for taking that to the next stage. If it’s had a good track record in managing budgets and improving services, they would be enabled to take even more responsibility for budgets and the direction of integrated care.
We’ve had warm words before about integrated health in Our Health, Our Care, Our Say but nothing much has happened since. There is a need now to follow through and say how this is going to happen.
Will patients be allocated a key worker?
Very often patients look to their GP to take on the key-worker role. But for patients with complex care needs, there is a danger they are falling between the cracks.
For me the question is who needs to take on the co-ordination at different points of the pathway, rather than drafting another group of workers to take on this role. So, for example, for a patient with breast cancer the best person for this role might be the breast cancer nurse at the hospital.
It might also be about giving the patient more control over how their care is organised and individual budgets have a role here. Personalised health budgets would mean the patient can themselves become their own care co-ordinators.
Will integrated care require bigger premises?
Not necessarily. We’ve already heard the term ‘virtual polyclinics’. Most chronic disease management happens in primary care, so most patients need a really well-developed primary care team.
Policymakers are talking about how to build much stronger bridges between primary and secondary care. What people need is ‘care’ rather than primary or secondary care. Much more important than premises is IT.
I’ve just come back from looking at models in the US where they have electronic patient care records and this is a very important enabler of integrated care. GPs have good IT systems but if the hospital can’t access them then that’s a large barrier to integrated care.
Professor Chris Ham is professor of health policy and management at the Health Services Management Centre, University of Birmingham. He is also former director of the Department of Health strategy unit
BOLTON, EPSOM AND BIRMINGHAM: THREE MODELS OF INTEGRATED CARE
1 Bolton’s managed diabetes network
• A local managed diabetes network that provides integrated care to patients with diabetes.
• Bolton Diabetes Centre set up in 1995 involving a community-based specialist team focusing on 15-20% of diabetes patients, mainly those with complex needs or in transition.
• The ethos of the team is to facilitate and provide quality patient-centred diabetes care throughout Bolton through education and expert practice.
• Since the mid 1990s the main emphasis has been on training up primary care teams to provide a wider range of care.
• Vision now is that care should be patient-centred and not organisation-centred.
• Objective is that Bolton should have a fully integrated service without gaps or duplication and with smooth and quick referral from primary care to specialist advice.
2 Epsom Downs Integrated Care Service
• GP Dr Tim Richardson’s practice purchased and moved into the ground floor of the old Cottage Hospital in 1991. The UK’s first independent day surgery unit was later created on the top floor of the hospital and the practice took over the ownership and management of this day surgery facility in 1998.
• In 1996 the practice undertook a total purchasing pilot for a wider range of services than had been possible under fundholding and operated as a sub-committee of the health authority.
• The practice was keen to be recognised as a provider organisation, and became a first-wave PMS plus provider in 1998.
• Under PMS plus the practice provided a range of services. These included:
– specialist clinics that involved GPs working with specialists
– diagnostics including X-ray, ultrasound and vascular Doppler
– therapy services, for example physio, chiropody, audiology and dietetics
– open access endoscopy and a full range of specialist day surgery
• The practice was able to achieve savings of about £500,000 each year for the practice population of 25,000.
• Negotiation of an SPMS contract under Epsom Downs Integrated Care Service (EDICs) involves a network of 16 practices working together to serve a population
of 121,000. The practices are able to provide outpatient services at 65 % of the cost at the local NHS trusts and day surgery at 87% of the cost.
• Almost all the practices’ referrals go to EDICs and more than 50% of those now go to local rather than acute hospital services.
• The aim now is to extend beyond outpatient services to whole care pathways by taking on a full capitated provider contract.
3 Birmingham and Solihull Kaiser pilot
• Inspirational visit by six local clinicians from the NHS trust and two PCTs to Kaiser Permanente in northern California to explore possibilities of running services
in an integrated way with clinicians leading the development of services.
• On their return, commitment was gained from the PCTs and foundation trust leaders to a programme called Working Together for Health, based on the following principles:
– emphasis on integration of care
– priority given to keeping people out of hospital
– active management of people to prevent illness and improve quality of life
– promotion of self-care and partnership in care between clinicians and patients
– clinical leadership to drive change
– use of information technology to support integrated patient care and change management.
• To achieve this the partners have committed themselves to:
People competency Large numbers of staff have gone through a development programme in leadership and personal effectiveness so staff can better understand their own and others’ behaviour and so interact more effectively.
Within the foundation trust the leadership style of clinical directors, if found to be inconsistent with the Working Together ethos, is explicitly challenged in the appraisal process.
Process competency The ability to record measure and redesign the patient pathway.
This has involved training clinicians and managers in use of process mapping and lean thinking to redesign pathways so that they understand the current processes experienced by patients and uncover steps that add no value to the patient journey.
Pound competency Addressing the fragmented approach of purchasers and providers by pooling some budgets between health and social care.
• Examples of service innovation so far – award-winning orthopaedic service, integrated COPD service, integrated diabetes kidney service.
Source: Professor Chris Ham on behalf of the Nuffield
Trust. Integrating NHS Care: Lessons from the front line and Clinical Integration: Five years’ experience in Birmingham and Solihull. 2008
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