Upload
nuffield-trust
View
487
Download
1
Tags:
Embed Size (px)
Citation preview
Commissioning and integrated care
Dr Jennifer DixonDirectorThe Nuffield Trust
16 March 2010
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
1. Current context: some features
Financial challenge
Rising demand
System incentives misaligned
Unengaged clinicians
Weak commissioning
Avoidable ill health and costs
Current context:
Incremental efficiencies will help but..
....Change in landscape needed
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 andinstitutions… collaborate and communicate toensure appropriate exchange of information andco-ordination of care”
(Institute of Medicine, Crossing the Quality Chasm, 2001)
2. Commissioning
‘needs assessment, resource allocation, service purchasing, monitoring and review’
Objective: health
Incentives currently not aligned in system
Commissioning
History– Impact
– Small
– Transaction costs
Now– PBC limp
– PCTs: Little control over volume
New
Managerial and analytic capacity
Performance management
3. Why integrated care?
Biggest efficiency frontier:
Care of older people
Care of people with long term conditions
Avoidable emergency admissions
Rising emergency admissions
HES
Year-on-year increase
Increase against
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
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…
4. What is integrated care?
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)
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
Types of integration III
Virtual integration
- a network of collaborators
Real integration
- a single organisation
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
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’
More radical health care examples
Trafford: current service sectors
Acute provision
GP1
GP4GP2
GP3 GPn
PCT
Community services
Non-PbR services
Outpatients and
diagnostics
Inpatient, daycase, specialist
Are these demarcations necessarily helpful?
(Independent)
PCT
Formalising clinical leadership/ enhancing local control
A FOUNDATION TRUST…?
…MADE UP OF ‘MEMBERS’ ON GP LISTS…?
Community services
Non-PbR services Outpatients
and diagnostics
GP1
GP4GP2
GP3 GPn(Independent)
Consultants, GPs and nurses/ AHPs as partners?
Integrated Care Record
Inpatient, day case,
specialist
A FOUNDATION TRUST?
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
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.
More radical health and social care examples:
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.
NE Lincolnshire Care Trust Plus
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
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.
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
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
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)