“The future of health”: Toby Lambert

10 December 2014

Monitor and making integrated care happen

There is an undisputed, urgent need for person-centred, coordinated care in the health and care system. Around 15 million people in England have a long term condition (LTC) that can be managed but not cured, such as hypertension, dementia or diabetes. LTCs absorb 70 per cent of the money spent on health and social care in England.1 By 2018 people with complex, multiple LTCs will number 2.9 million.2 LTCs particularly affect the lives of older people.

Provider collaboration is equally important, however, for services that depend on networks, such as cancer care. These are the groups that often find care is not well joined up, leading to gaps or duplication in service delivery, fragmented services, worse treatment outcomes, and a poor patient experience.

Integrated care relates to care within and across different NHS services as well as between the NHS and social care, with a focus on people not systems. In all Monitor’s functions we work with others, including key national stakeholders, to remove any barriers and consider how to enable integrated care. Monitor’s duty is to enable services to be delivered in an integrated way, which reflects a broader recognition of how important this issue is. We also see it as an opportunity to improve care for the patient. Integrated care can reduce resource use but offers many other benefits for the patient, such as better quality of life and experience of care.

One of the most commonly heard complaints from patients is that they have to repeat their story time and again to different healthcare professionals. With our partners in the Integrated Care and Support Collaborative, Monitor commissioned National Voices to develop a narrative for “person-centred, coordinated care”.3 The narrative includes “I” statements that can help to define what integrated care means for an individual, such as “I am always kept informed about what the next steps will be” and “I always know who is coordinating my care”.4

In the “extensivist” model of integrated care, a general care provider is fully accountable for a patient’s outcomes and overall budget, and care follows the person regardless of setting.

Of course, this is just one model for delivering integrated care. Monitor aims to provide the flexibility needed to allow new care models to emerge and encourage provider innovation. Our assessment process can accommodate new organisational forms, such as integrated care organisations, as long as they are well led, sustainable, and meet legislative requirements that more than half their income is for NHS purposes. The design of new models of care is being given momentum by certain programmes we support. An example is the integrated care “pioneers” programme, through which local areas can share how they have used innovative approaches to deliver patientcentred and coordinated care.

We have made changes that allow for greater flexibility in payment. Commissioners and providers can now choose to use, and inform us of, their own payment mechanisms that are good for the patient. In this way the tariff is an aid to, rather than a barrier to, innovation. Monitor has also been supporting local areas to link patient datasets so that pricing can be more accurately calculated under new payment designs.

There is no inherent contradiction between the drive for patient choice and provider competition and greater integration; both have a role in improving care. Integration means bringing together different services that are not in competition with each other. But we are aware integrating different services, particularly at scale, is a complex task and reconciling integration, choice and competition can seem challenging. We are therefore, through competition supplementary guidance, advising the sector of the potential risks of planned approaches as well as highlighting the opportunities of adopting competitive processes. By ensuring patient benefits are always considered first and foremost, no tensions should ever arise.

The Royal Marsden’s “Coordinate My Care” initiative is one example of successfully integrated care without hindrance from competition rules. It centres on a care plan shared electronically between providers of urgent care. These include ambulance control staff, NHS 111 operators, GPs, out-of-hours GP services, hospitals, nursing and care homes, hospices and community nursing teams. There is undoubtedly more work to be done in strengthening the evidence base for integrated care, and in making it the norm. We were involved in choosing 14 pioneering integrated care services across England as beacons of best practice. Our “pioneers” are now helping us identify the local and national barriers to integration.

Because Monitor is responsible for several aspects of regulation in the health sector we are uniquely placed to encourage and support the integration of care. It is important for the patient and important for the health and care system as a whole as it strives to make best use of the available resources.

Toby Lambert, Strategy and Policy Director, Monitor
@MonitorUpdate

Notes

1 Department of Health (2013), Improving quality of life for people with long term conditions.

2 Department of Health (2013), Long term conditions compendium of information.

3 Such as the Department of Health, NHS England, Public Health England, the Local Government Association, the Association of Directors of Adult Social Services and the Social Care Institute for Excellence.

4 NHS England (2013), A narrative for person-centred coordinated care.

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