Developing integrated care in the English NHS: the challenge for commissioners

The Future Forum has put integrated care at the heart of NHS reform. But who will ensure that integrated care is not crowded out by the emphasis on competition and any qualified provider, and what can clinical commissioning groups do to stimulate providers to work together to meet the needs of patients?

New research I have undertaken with Judith Smith and Elizabeth Eastmure draws on the experience of primary care trusts (PCTs) to suggest some answers to these questions. The research surveyed PCTs in England to understand how they were using their leverage as commissioners to promote integrated care.  PCTs in the survey focused on various areas of care including end of life care, out of hours and emergency primary care, and services for people with chronic diseases such as diabetes and chronic obstructive pulmonary disease (COPD).

One of the strongest messages from the research is that commissioning integrated care is not easy. Not only did we struggle to find examples to include in our survey, but also PCTs faced many practical challenges in undertaking innovative commissioning of this kind. These challenges included deciding the scope of services to be commissioned, the contracting and procurement route to be used, and the incentives to put in place.

Several lessons can be drawn from the experience of PCTs as the NHS Commissioning Board (now NHS England) and clinical commissioning groups prepare to take on responsibility for commissioning. Three stand out. First, groups will need support from the NHS Commissioning Board as they set about commissioning integrated care. This includes advice on methods of contracting and procurement, outcome and quality measures to include in contracts, and the tariff and incentives to use.

Second, the government must ensure that Monitor and the NHS Commissioning Board support both competition and integration. This includes recognising that competition for the market is needed alongside competition in the market.  Competition for the market is likely to be particularly appropriate in the case of unplanned care and some specialist services where provider networks might be awarded contracts by commissioners to provide care. These contracts could be put out to tender on a regular basis, for example every five years, to ensure providers are kept on their toes.

Third, work is urgently needed on how to create the right incentives to support integrated care. Payment by results was designed primarily to support choice and competition in relation to elective care at a time when the NHS budget was growing significantly. Alternative forms of payment are required to support integrated care, especially for people with chronic diseases and to support more coordinated unplanned care, when funding is very tight. 

Various options are available, including combining payments to cover an episode of care or care pathway, taking forward the ‘year of care’ that has been tested in diabetes, and experimenting with capitated budgets for specific diseases or populations. 

Any approach that focuses on funding for diseases or medical conditions will face the challenge of ensuring that the scope of services is well defined to avoid cost shifting, especially for people with several conditions. A more promising route may therefore be to allocate a capitated budget to a provider that takes responsibility for all or most of the needs of a defined population.

One of the case studies in our research involved a primary care provider that did precisely this, with the support of an independent sector provider. Its focus was on high risk patients with chronic diseases where there were opportunities to provide more care closer to home and reduce avoidable hospital admissions. 

The opportunity available to clinical commissioning groups is to build on examples such as this, learning from our research, and showing how commissioners can lead implementation of the vision set out by the Future Forum.

Chris Ham is chief executive of The King’s Fund and co-author of: Commissioning integrated care in a liberated NHS (Sep 2011), the second in a series of reports that Nuffield Trust is publishing as part of its research project: The quest for efficiency in the English NHS. 

Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.