1. Commissioning and integrated care
Dr Jennifer Dixon
Director
The Nuffield Trust
16 March 2010

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

4. Current context:
 Incremental efficiencies will help but..
 ....Change in landscape needed

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

10. 4. What is integrated care?

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)