The health debate will rage for a while yet, but the core themes of the current NHS reforms are clear – accountability for commissioning, quality of care, competition. GPs in the NHS Future Forum report emphasised integration and co-ordination of services, recommended clinical commissioning and sought a slower pace for change. As with all previous NHS reforms, the Health and Social Care Act concentrates on form, not function; the critical question is, and remains – how does commissioning need to change?
Primary Care Trusts and their predecessors were still comparatively new commissioners in commercial terms. The competitive agenda of World Class Commissioning and the commissioner/provider split were only introduced some seven years ago. Before then, integration and co-ordination of services was an easier challenge, given contestability was less of an issue. The NHS has defended localism whilst trying to embed national market changes (Foundation Trusts, ISTCs, private sector providers and the Hinchinbrooke franchise experiment). It purchases high cost (acute) interventions on price/case and contracts for lower cost (community) interventions in block contracts. These market tensions combine to make quality provision at reasonable cost a serious challenge.
A Competitive Model for Integrated Care
The current debate could be unlocked if it was possible to create a competitive model of integrated care. Current health service redesign thinking makes this difficult. Clinical commissioning mostly concentrates on clinical pathways, seeking to improve the quality of the patient experience by case co-ordination. Little or no thought is given to the ‘model of care’ i.e. how the whole system is working to deliver a multiplicity of services to a demographic group or patients with complex needs. Consultancy firms, meanwhile, advise the financially challenged health economies on turnaround by fixating on reducing crisis management costs as these are the high ticket items. This concentration on the management of acute episodes fails to track patient costs across the system, and perpetuates the myth that care is always cheaper in the community.
In South East Essex PCT, Phoenix Interims supported two groups of people working together to crack this conundrum – a competitive model of integrated care for the elderly. The first group was a reference group of GP commissioners; the second was a whole systems partnership with patient representatives and all key stakeholders across health and social care and the voluntary sector. Starting with the traditional savings schemes that any health economy will recognise – admission avoidance, improvement in health and social care community response times and treatment, appropriate triage into and use of community beds, it was my privilege to lead these two groups of people to co-design a whole system model framework that could be applied across any health economy and enables competition in the long-term.
Before we look at the model of care, let’s deal with the issue of contestability. The main public sector providers of community care for the elderly are normally social care, the mental health partnership and community health services. South East Essex PCT chose to find a host for its community health services for two years, asking the ‘acquiring partner’ to work with the PCT to develop the model of care during that period in preparation for competition at the end of that period. Southend Borough Council meanwhile was comfortable with the concept of secondment into a partnership model. Elements of intermediate care provision have been delivered by a joint workforce for several years; the Care of the Elderly Programme worked through partnership agreements. So co-design of a model of a longer-term Care of the Elderly service with the main providers was made possible by intelligent commissioning.
What was the learning? If in due course a fully integrated model is contested, then this will not necessarily need to be a separate entity, but it will need to be a recognised service. Other healthcare services are delivered on a ‘lead provider’ arrangement, and there is no reason why a Care of the Elderly service cannot be run this way. So the key element of the service that will need to be contested is the leadership of the service – other elements could then be kept competitive by inter-provider contractual arrangements and with a requirement on the lead provider to provide best value.
Developing Leadership for the Service Model
Now to the model of care that was designed by the Care of the Elderly GP reference group, and the South East Essex Care of the Elderly Partnership. Both groups of people were deeply committed to improving the quality of patient care whilst decreasing cost; they quickly realised that driving acute costs down was only one part of the full care picture. Faced with a request for a commissioning framework that would integrate savings schemes and action-research learning from pilots into a cohesive model of care, I found myself realising how similar the market design of integrated care is to the market design of utilities. Supply capacity (capital infrastructure) for water or electricity is a key part of market design; community (health, social care, housing, voluntary service) infrastructure is a vital part of market design for Care of the Elderly.
The model we designed is represented pictorially below. It included a full re-design of the health and social care community infrastructure into either a reactive urgent community response or a proactive integrated locality team; united by a single point of community referral in due course these teams and those supporting community beds will provide all out of hospital services for the elderly. The decisions about ‘right care, right place, right time’ are made by health and social care professionals acting as a multidisciplinary team through this community referral hub; a multidisciplinary approach was adopted to triage at the front end of Southend University Hospital Foundation Trust.
The most interesting development from the GP commissioner reference group was their support for a specialist Care Home peripatetic service. To serve South East Essex’s 140 Care Homes on the current model (with residents registered with any of c. 160 GPs) is not sustainable; a specialist service if commissioned over the next two years could dramatically improve care, particularly for dementia patients and those at the end of their lives. The whole system appointment of a ‘community geriatrician’ marked a clear beginning of a platform for a ‘leadership model’ for Care of the Elderly. The common ground in the White Paper and the NHS Future Forum report is the importance of effective clinical decision making. Add in the professional judgement of social care colleagues, a commitment to partnership and an intelligent approach to commissioning and there is perhaps a way forward that can achieve accountability, quality of care, and competition.
Will Lead Provider Arrangements Work?
Sadly it is unlikely that the appointment of a lead provider on its own will solve all the issues around competition and integration. The really thorny issues are partly operational, and partly economic. Although a Single Point of Referral is now well established in Southend bringing together the health and social care points of access, its management of out of hospital capacity has failed to relieve sufficient pressure on a very acute based system (Southend does not have any community hospitals and below national average number of intermediate care beds).
Southend has a lead provider for much of its out of hospital model. It has just been rightfully selected as one of the Integration Pioneers. It is also currently reviewing its capacity, acknowledging the challenges in its current urgent care system.
Torbay, as a recognised leader in integration, has also found the changes resulting from the Health and Social Care Act challenging. By splitting from Torbay health commissioning and by taking on the South Devon community contract it is facing less integrated commissioning funding streams, and is learning to balance those competing interests.
Cambridge and Peterborough are currently commissioning a Care of the Elderly model, relying on a lead provider. Considerable thought has been given in the commissioning process to the powers needed by that lead provider – but many acknowledge that one lead provider on its own, however partnership-based, will struggle to balance all competing interests.
The Importance of Independent Leadership
Competition and Integration can co-exist – but only if effective clinical decision making is balanced with the professional judgement of social care colleagues, a commitment to partnership working and centred on accountability, quality of care, and competition.
Whole system development requires, time and again, someone or some organisation to take an impartial view – to make the difficult judgements between market development and the day by day experience for those people every professional is trying to serve.
It is unlikely that local commissioners on their own are able to make all the judgements on competition and integration. Local authority interests in many localities still conflict with those of their health commissioner colleagues. Monitor’s role in this area is still developing, but so far it has failed to find frameworks to provide clear guidance on resolving the competition/integration tensions.
Much of the development of the Southend Care of the Elderly model was based on the findings of a consultant geriatrician review of just under 300 patients identified through combined risk stratification to be most likely to need changes in their care provision. Torbay focuses its energy on Mrs. Smith’s experience – again, seeking an objective standard in a world of competing interest. And it involves its clinical reference boards in actively making those whole system decisions.
The balance between competition and integration will always need to be a judgement call. Often in the short-term that will need to be one person’s judgement after taking soundings and seeking governance – as with an Interim Director of Change. In the longer-term it seems that competition and integration will only be able to be well balanced if experienced, independent local leadership across provider and commissioner are prepared to act explicitly in the best interests of the service user or the care system. This will be an immense challenge – so we will all watch the Integration Pioneers with interest…