© Nuffield Trust Commissioning integrated care: insights from our research Dr Judith Smith Head of Policy, the Nuffield Trust Professor Chris Ham Chief Executive, the King’s Fund 22 September 2011

© Nuffield Trust Agenda The research project Case studies of commissioning integrated care Emerging themes Policy implications

© Nuffield Trust The research project Project aim To understand how NHS commissioners were using their leverage to develop more integrated care To examine the extent to which such attempts were focused on efficiency, as well as service quality To consider what this means for commissioning in economic hard times, and in the new reform context

© Nuffield Trust The research project (2) Project approach A questionnaire survey of all PCTs in October-November 2009, seeking information about innovations in commissioning A survey by and phone of SHA commissioning leads Approaches to national organisations Use of an expert advisory group Review of US literature on payment reform Case studies of innovative examples of commissioning, developed via research visits and interviews, and review of documents

© Nuffield Trust The research project (3) What we thought we might find Commissioning care pathways rather then episodes of care via Payment by Results Commissioners working with lead providers to promote integration, and the use of subcontracting by these lead providers New forms of payment to incentivise integration, such as payments for care pathways and other forms of payment bundling

© Nuffield Trust The research project (4) What we found PCT survey had a disappointing response, despite a follow- up chaser Survey of SHAs, and discussions with advisory group and national organisations added some examples Overall, most examples were provider-initiated, and it was difficult to find ones that were led actively by commissioners We drew up a long list of examples, from which a number of case studies were selected

© Nuffield Trust Case studies of commissioning integrated care Birmingham North and East PCT – commissioning integrated care for people nearing the end of life Milton Keynes PCT – seeking to contract an ‘accountable care organisation’ for a whole programme of care Tower Hamlets PCT – commissioning outcome-based diabetes care from networks of providers Smethwick Pathfinder – a group of GP practices holding a capitated budget for managing the care of people with long-term conditions

© Nuffield Trust Case studies of commissioning integrated care Cumbria PCT and practice-based commissioning – commissioning integrated diabetes care across a county, using a new specialist care organisation Knowsley PCT – contracting with a lead specialist provider to deliver the full range of cardiovascular care for a population with major health inequalities Somerset PCT – commissioning an integrated COPD service from a partnership of BUPA and a company formed of local GPs West Kent PCT – commissioning a social enterprise to deliver integrated out-of-hours primary care and emergency primary care, based in the hospital A&E

© Nuffield Trust Emerging themes – the cycle of commissioning Needs assessment and service specification – took up considerable time and resource, helped with engagement, but hard to move to implementation Contracts – a range of mechanisms used, including PMS, GMS and adaptations of PbR and acute contracts. Seems there is more potential to use existing mechanisms Tendering and procurement – costs of this were prohibitively expensive in some cases, yet others were able to contract for new forms of care across organisations Outcomes and incentives – the value to be had from linking payment to expected outcomes, and doing this in a phased manner

© Nuffield Trust Emerging themes – facilitators of new approaches Managerial leadership – senior support, drive, and risk- taking Clinical leadership – as commissioners and providers Primary care-led commissioning – PBC as a catalyst for service review, redesign, and change Data and IT – critical to contracting, tracking outcomes, developing sophisticated payment approaches

© Nuffield Trust Emerging themes – facilitators of new approaches (2) The registered list of patients – important for population- based approaches and budget-holding Provider engagement – it is costly for providers to be involved, and a risk for them Time and persistence – takes a lot of time and resource to plan and implement major change

© Nuffield Trust Policy implications Central support for commissioning of integrated care is vital The role of Monitor will need to be crafted in a way that promotes both competition and integration There is a need for further and more extended experimentation with tariff and incentives for integrated care A range of approaches to contracting and procurement will be needed

© Nuffield Trust Policy implications (2) Some GP commissioners will want to be able to ‘make’ as well as ‘buy’, and policy on conflicts of interest will need to address this There is a need to think again about how the commissioner-provider split might operate in future, perhaps testing out new integrated provider-funder organisations In whatever approach, aligning incentives across primary and secondary care, and also social care, will be vital

© Nuffield Trust To conclude ‘ The balance of risks and incentives placed on commissioners and providers in the NHS appears at present to be wrong. Commissioners seek to develop more population-focused and preventative approaches to care [...] yet providers remain incentivised to increase activity and expand services within their organisation. Perhaps the strongest message from this research is that PCTs have struggled to put providers sufficiently at risk in relation to developing better integrated and more efficient care.’ Ham, Smith and Eastmure, 2011, p35

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