Clinical commissioning and integrated care

Following the NHS Future Forum report, the Government has put integrated care at the heart of its vision for England’s health system. Setting out his priorities for the NHS, David Cameron pledged that the Government’s reforms “will not break up or hinder efficient and integrated care – we will improve it.” The revised Health and Social Care Bill sets out measures to encourage greater coordination between services: through Clinical Commissioning Groups, Clinical Senates, Health Wellbeing Boards and a revised role for Monitor and the National Commissioning Board. However, while many welcomed these changes there remains debate on how these measures will work in practice.

In the wake of the NHS Future Forum report, Reform held two lunches to explore how clinical commissioning will deliver integrated care. These lunches were held in partnership with Novo Nordisk, a world leader in diabetes care. Reform’s aim was to bring together key individuals and organisations that can make the Government’s vision a reality, including GPs, NHS leaders, patient representatives, policy makers and journalists. The lunches were covered extensively in the media with a front page story in The Times highlighting Dr Peter Carter’s comments in favour of closing failing hospitals and departments and moving care into more appropriate settings. The discussions highlighted the challenges and the opportunities facing the NHS, and the barriers to reform.

The challenge

Healthcare costs are rising in every developed country. To meet the challenge of rising expectations, new technology, changing lifestyles and an ageing population the delivery of healthcare has to be reformed. Making health services better suited to meet the costs of long term conditions is a major opportunity to make healthcare affordable. Long term conditions now account for 70 per cent of health spending and diabetes alone accounts for 10 per cent of the NHS budget. These costs are due to complications, as Viggo Birch, Vice President of Novo Nordisk Europe argued: “almost 50 per cent of the people with diabetes today in the UK, but basically everywhere else as well, are in so-called bad control. They are not treated adequately which is the main cause of the human, social, financial cost of diabetes.” The current fragmentation of the healthcare system also results in poor use of drugs and technology, creating inefficiencies. Consequently, integrated care has the potential to better manage patients with long term conditions and reduce the costs.

What is integrated care?

While there is a broad agreement on the need for integrated care, there is uncertainty over what integrated care is in the context of the NHS. As Michael Sobanja, Chief Executive of the NHS Alliance claimed, “I don’t know what good integrated care is. I do know what it isn’t.” However there are recognisable integrated systems abroad with strong family resemblances. The models operating successfully in America, such as Kaiser Permanante, or in Valencia, such as Torrevieja, embed strong incentives, both financial and non-financial; employ joined-up information technology systems that make it possible to access patient records from a range of settings; and invest heavily in continuing professional development, with an emphasis on developing a culture of clinical leadership, ownership and accountability.

While much of the political debate has focused on integration between primary and secondary care, many of the attendees urged that attention should also be given to “horizontal integration” within primary care and within hospitals, as well as integration with social care. As Dr Amit Bhargava recognised, “integration is what the patient feels rather than what we think is a good integrated plan”. Dr Charles Alessi also reflected that integrated care is a step towards “population health” and Dr Shane Gordon called for a “managed care model”. The example of community care shows that you can break institutional addictions and move care into a new setting by having a care manager (such as a specialist nurse or a general practitioner) with clear financial accountability.

The barriers

According to Michael Sobanja “integrated care for 25 years plus has been the elephant in the room for the health service that we haven’t been able to achieve.” Dr Jennifer Dixon and others referred to the success of Kaiser Permanente and other North American providers of integrated care, but there was frustration that the NHS has been unable to learn from these examples. As Jennifer suggested this is “the organisational financial incentives environment just doesn’t allow this thing to grow.” The problem of incentives was frequently highlighted. According to Dr Shane Gordon “unless this is addressed no jiggling around of who sits in the commissioning deck chair will solve the problem.” Payment by results, the tariff and staff contracts were all singled out to be in need of reform. Others also suggested that the relationship between primary and secondary care needs improving, and investing in retraining staff to deliver care in different settings.

Reforming healthcare to meet the financial challenge and deliver integrated care demands a redesign of hospital services. Speaking at the first seminar, Peter Carter of the Royal College of Nursing suggested that “one of the things that in this new era will have to be grasped is the fact that particularly in our metropolitan areas we have far too many acute hospitals…and that is draining away so much of the money”. However, disinvesting in acute care and focusing resources on preventative medicine and community services faces major obstacles. Political interference and local media often fight plans to redesign hospital services, while the NHS has also failed to present a narrative and make a case for change. As Peter Carter argued “the NHS is going to have to reappraise its ability to do intelligent service redesign and intelligent commissioning”.

The opportunities

The seminars demonstrated that while there is potential for the Government’s reforms to improve the NHS, there are also significant concerns and doubts on their actual impact. Many recognised that commissioning in the NHS needs to be improved. Aligning clinical and financial responsibility is “the holy grail” of the reform package according to Guy Boersma, Director of Commissioning and System Development, NHS South East Coast and others, while many were anxious that clinicians had full financial responsibility for delivering care. Peter Carter saw clinical senates informing commissioning groups of the immediate, medium term and long term needs of their communities, particularly around specialist care. George Leahy from the Department of Health saw commissioning for health outcomes as an opportunity to encourage innovation and allow commissioning groups to develop the most effective care plans for patients.

However, some expressed concerns about the new structures. As Michael Sobanja claimed, “one of the biggest threats of these arrangements is an unfettered grab on centralism in the new service as opposed to localism”. Mike Farrar of the NHS Confederation reflected that one possible consequence of the reforms would be a further fragmentation and centralisation of budgets, while others advocated capitated budgets that could unify organisational incentives. Peter Carter recognised much of the detail of these groups is still missing, particularly around governance and failure. In addition, there was a feeling that some clinical groups will not have the expertise or the scale to challenge large acute providers and move services out of hospitals and into the community. There was also much discussion on the potential conflicts of interests with hospital physicians on commissioning boards.

There was debate on the role of patients in developing integrated care. As Michael Sobanja reflected “Do we bolster the patient’s ability to integrate that care? Or do we attempt to integrate care for them and on their behalf?” Many people saw that patients can bring value to the commissioning (and decommissioning) process. According to Mike Farrar the NHS “need[s] to do more to empower patients to be more responsible with budgets”. Others felt that patient choice and personal budgets could really drive integration, while a more competitive healthcare market would create incentives for providers to deliver integrated care.

However Barbara Young of Diabetes UK argued that patients with long term conditions find it difficult to make informed choices: “patients constantly tell us all the time that they do not want to be the integrator of their care…they want somebody else to do that for them.” Although there was broad agreement that competition and integration are not alternatives, many stated that some of the world’s most efficient and high quality integrated care organisations have developed in competitive environments.

The way forward

The seminars revealed that new NHS structures and organisations will not be enough to deliver integrated care. Further reform is needed to make healthcare more responsive to patient needs. As Lord Warner, Former Minister for Health, recognised “if you want to drive changes, you drive these changes with the money. And if you don’t drive them through the money, nothing much changes.” He argued that “if we don’t start somewhere in this and start doing it with a financial system which incentivises this kind of pattern of service you want, the decision will be made for you because the decision will be made around what the National Commissioning Board decides to do.”