Removing the barriers to integrated care

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The momentum behind integrated care, generated by the work of the NHS Future Forum and Norman Lamb’s appointment as Care and Support Minister, has increased during 2013. Fourteen areas that will take forward integrated care at scale and pace have been identified; the establishment of the Better Care Fund will require all areas to develop plans to integrate health and social care; and changes to the GP contract are designed to reinforce the role of GPs in co-ordinating care for older patients.

Welcome as these developments are, many barriers stand in the way of translating policy aspirations into practice. While some of these barriers can only be tackled at a local level, others require changes in government policy if integrated care really is to move forward at the scale and pace demanded by current financial and service pressures. The most important changes are:

  • ensuring that provider regulation does not get in the way of partnership working
  • ensuring that quality regulation is not overly focused on organisational performance
  • developing payment systems that create incentives to integrate care
  • supporting commissioners to promote greater integration.

Taking each in turn, regulation through Monitor and the NHS Trust Development Authority has an essential role in ensuring that providers are well led and financially sustainable. The challenge in carrying out this role is to ensure that the regulators do not make partnership working harder to achieve by requiring providers to strengthen their balance sheets at the expense of the other NHS organisations they work with.

Our work with NHS organisations at a local level indicates that this is already happening in some places. If it becomes more widespread there is a risk that providers will, quite rationally, concentrate on their own survival to keep the regulators at bay. This will then make it difficult for providers to collaborate with commissioners and other providers to achieve closer integration of care in what could descent into a zero-sum game.

Developments in quality regulation present another set of challenges. Under its new leadership, the Care Quality Commission (CQC) is moving to strengthen inspection with an initial focus on hospitals, general practice and social care. In so doing, the CQC is putting the emphasis on assessing organisational performance rather than system performance, partly in response to well-publicised concerns about quality failures in hospitals, care homes and general practices.

This is understandable but risks downplaying the need to regulate how organisations work together to meet the needs of people whose care depends on different parts of the system being joined up. The actions of the CQC may in this way unintentionally force organisations to focus on their own performance, thereby giving less attention to how they can work in partnership to deliver high-quality and well-co-ordinated care.

It goes without saying that payment systems must create incentives to integrate care, and that Payment by Results was not designed to do this. Despite much talk of alternatives, such as year of care payments and capitated budgets, progress in developing more appropriate incentives has been painfully slow.

The partial exception is where providers and commissioners have taken the initiative – often under the radar – to do local deals. Ministers must now ensure that Monitor and NHS England take their responsibilities in this area seriously by developing currencies that support integrated care. They must also encourage a permissive environment in which different approaches can be tested without fear of retribution.

Last but not least, commissioners have a key role in promoting greater integration but this has become much more difficult since the population-based budgets controlled by primary care trusts (PCTs) have been fragmented between clinical commissioning groups, NHS England and local authorities. If integrated service provision is to become a reality then ways must be found to reintegrate commissioning responsibilities and budgets. Health and wellbeing boards have a part to play here but they remain in an early stage of development and much remains to be done to strengthen their role.

One of the ways in which commissioners can make a positive contribution is through the use of innovative approaches to commissioning care. These approaches include outcome-based contracts, alliance contracting, and prime-provider models. A few areas are actively testing these innovations and NHS England could do more to support and encourage this kind of work, including by ensuring these innovations do not fall foul of the market regulators.

All of these issues are being played out when financial and service pressures are growing by the day with the risk of a fiscal cliff appearing in 2015/16. Alongside action by ministers to remove barriers to progress, priority should therefore be given to the development of collaborative, system-wide leadership without which there is a clear and present danger that organisations will adopt a fortress mentality to cope with these pressures.

Looking back, there has been welcome progress during 2013 but, for those of us who have advocated integrated care for some time, it is premature to declare victory. A coherent and consistent policy framework is needed to support the undoubted commitment in the NHS, local government and the third sector to build on the foundations that have been established. In the absence of such a framework, policy aspirations will remain unfulfilled and patients and users will be the losers.

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John Hartley

Project manager,
Comment date
06 January 2014
"Outsource it and they will come" is not a policy to encourage integration.

Recently a hackney cardiology outpatient services were contracted out to... Homerton hospital! So now there is a new "outpatient" cardiology department, down the corridor from the pre-existing cardiology department funded by the local commissioning group.

Commissioning support units -
Could fund & mentor business hubs, to encourage new and existing social business enterprises to bid for primary health care contracts.

Instead, existing providers are squeezing out innovation and services are not getting and closer to the patient.

Harry Longman

Chief Executive,
Patient Access Ltd
Comment date
06 January 2014
Reading between the lines, you are saying that the regulatory and financial framework play against a system approach to running the NHS, which is the way to make real and sustainable improvements. Nice positive spin, but through gritted teeth?

Rustam Rea

Consultant in Diabetes,
Oxford University Hospitals NHS Trust
Comment date
08 January 2014
Fundamentally trust is needed between provider organisations to build clinical partnerships, the bedrock of integrated services. These partnerships should be based on a shared ownership of the health outcomes of the local population. This trust takes time, personal effort and organisational committment to build.

Sharing the financial risk and developing joint clinical governance across traditional health and social boundaries can go a long way to developing this trust and assure regulators of the quality and sustainability of the service for the population.

Roger Steer

Healthcare Audit Consultants Ltd
Comment date
09 January 2014
My mother in law in France needed care at home for Alzheimer's.
It worked smoothly and effectively over many years and she eventually died at home.
It was very costly but cost was not a limiting factor.
Once entitlement was established funds flowed.
I would suggest that the NHS look at what makes for success elsewhere.
Sometimes it appears that the NHS didn't learn a thing from Enthoven.
Managing an integrated budget leads to denial, delay , dilution , deferral etc as budget management is prioritised over care management and inefficiency and transaction costs proliferate as bottlenecks and hurdles are created , both deliberately and inadvertently.
Either it is more efficient to provide integrated care and it should have an open ended budget or it is not more efficient and we stay as we are.
I'm not sure what is the current thinking.

George Farrelly

The Tredegar Practice
Comment date
10 January 2014
Will the proposed abolishing of GP practice geographical boundaries help or hinder integrated care?

Mary Taylor

Health professional,
Comment date
28 January 2014
So far, the integrations look like the staff feared; an excuse to downgrade the NHS half to the level of the adult social care half. Lots of money saved as nurses head toward the system used in ASC of no pay for driving time, limited time with patients, less time to plan and share caseloads with teams.......Eventual fragmentation and outsourcing on the horizon? I don't think these schemes are occurring for the right reasons - otherwise the two sides would be going in to the same computer patient systems

dr david rapp

retired gp,
Comment date
28 February 2014
Its such a great pity that a worthy observer of the NHS,Chris Ham,cannot state directly that numerous initiatives by the Coalition and previous Governments constantly miss the point as to how to improve the functioning of the NHS because they do not understand how Medicine as a "commodity " works.Lots of hard work by CCGs etc flounders because the systems of control and payment set up by Government do not reflect the reality of Medicine in all its complexity.Much clearer tangible explainations of the issues involved should be honestly be presented to the public so that realistic expectations can be meet.For instance,proper acknowledgement of safe staffing levels:Honest explainations of the financial mess created by PFIs and the difficulties of re arranging clinical care coping with the financial hangover.I feel lots of eminent observers are pussy-footing around the realities and meanwhile hard working staff on the ground get the blame for not achieving in an unrealistic framework

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