A speedy selection process has led to 16 projects being picked for integrated care pilots. Can they improve quality and test bold ideas or have we seen it all before, asks Helen Crump
Last week the final building blocks of one of Lord Darzi’s more curious policies were put in place.
The health minister’s next stage review promised to test new ways for primary care trusts to commission more joined-up services from “innovative groups of clinicians” through so-called integrated care pilots.
“I’d hope people were experimenting anyway, whether or not they’re in this scheme”
Nine months and one speedy selection process later, the Department of Health has whittled down more than 100 applications to a final list of 16. These range from “horizontal” links between GPs and social services to “vertical” models joining community and acute services.
Integrated care has the potential to boost efficiency by getting clinicians to work more closely together. It does this by giving one organisation responsibility for providing care that historically would have been delivered by several.
Ultimately this means commissioners could buy a complete service for a set of patients - such as a service encompassing primary and secondary care tailored for people with long term conditions - from a provider, rather than simply a quantity of a particular type of treatment.
The provider gets to re-think how it delivers all the care, ironing out inefficiencies and improving quality and patient experience.
With both Labour and the Conservatives promising to put more local commissioning power in GPs’ hands, schemes that base greater integration around GP practice populations could end up taking on a much greater significance. But this will only happen if clinicians and managers can be convinced that it will produce improvements.
One scheme using some of the principles of integration has already been operating for some months in Surrey.
Run by a practice based commissioning group and management support organisation Integrated Health Partners, it is extending some of the end of life services cancer patients receive to patients with lung disease and heart failure.
Patients get medication checks and have care plans explained, which improves quality and also cuts waste.
Managing director Oliver Bernath says the organisation is questioning coding for acute services worth “tens of thousands of pounds”.
The project is being funded by practice based commissioning cash with some PCT support money to get it started, but Dr Bernath says it will create an in-year saving for Surrey PCT.
Redrawing organisational boundaries is not without risk - hence the pilots. National primary care director David Colin-Thomé has suggested them as a way of testing ambitious but “risky” ideas, which could ultimately shape policy. All of the schemes are for populations smaller than PCT areas.
But is it possible to create future national policy direction from such a small number of self-consciously local initiatives?
NHS Confederation policy director Nigel Edwards says: “There are a lot of good things about these pilots but piloting national policy probably isn’t one of them.
“The whole point about a pilot is that there should be a methodology you can generalise, otherwise you’re paying people to innovate, which then begs the question: why not let more people experiment more widely?
“I’d hope people were experimenting anyway, whether or not they’re in this scheme.”
Game of risk
Mr Edwards thinks the pilots may well reveal fresh approaches to integration and test the thesis that aligning clinicians more closely produces better results. They might also showcase what it is possible to achieve through approaches that tear up the NHS organisational rulebook.
But a “bigger push” will be needed in order to reach a tipping point where it is possible to demonstrate systemic quality and efficiency improvements, he says.
Dr Colin-Thomé believes the pilots are as much about highlighting different approaches to leadership as testing potential organisational structures. In fact, some of the pilots are too small to operate as standalone organisations, he says.
Having a project designated as a pilot gives participants permission to set up more risky schemes but with a safety net - rather than imposing drastically different new models on the NHS straight away. The schemes will be closely evaluated by Rand Europe and Ernst & Young.
But Dr Colin-Thomé says he hopes schemes that did not make the final cut as pilots will also progress their ideas and create local metrics to measure them.
Another paradox surrounding the schemes is that considering the huge influence US integrated healthcare management organisation Kaiser Permanente has on NHS thinking, more Kaiser-style models of integration are not being tested.
In the US, patients sign up with Kaiser and receive all or most of their care from the organisation. Where the organisation does not supply the care needed, it buys it on behalf of the patient. Kaiser’s approach has generated interest at the Department of Health, but the schemes proposed in the pilot tend to be smaller scale than what Kaiser does.
King’s Fund senior fellow Nick Goodwin, who has responsibility for integrated care, feels that the schemes could have been more radical.
“I had expected at least one of these to be really different,” he says. “Although they are all really interesting, really good and probably really worthwhile, we’ve seen a lot of this before.”
Mr Goodwin says he would have liked to have seen provider organisations “taking on some of the risk of managing a budget as well as providing care” under the pilot schemes.
Dr Colin-Thomé says patient choice is crucial over here, and this explains why there are no exact Kaiser copies.
“Kaiser’s main strength is clinical leadership. Kaiser has good examples around clinical involvement but when we start to look at policy around organisations you need to look broader than Kaiser,” he says.
A question of choices
“In the US, lots of integrated care organisations restrict choice for patients - the choice is to go to another organisation.
“In England we’ll be saying there won’t be as much choice as that [in terms of local organisations] - so how do we get choice within these organisations?”
This also explains why none of the schemes match PCT boundaries. If they did, there would be a risk that all providers a PCT area joined, creating huge monopolies and inhibiting choice.
Participants are confident they will be able to prove their schemes’ worth. NHS Cumbria deputy chief executive Anthony Gardner and GP locality lead Hugh Reeve are overseeing two of them (see box).
They recognise managers and clinicians must put aside traditional suspicions about devolving responsibility to providers for projects like theirs to work. Dr Reeve says he has already had to bat away allegations that the Cumbrian scheme needs to be “controlled” because the participants are “in it for the money”.
Mr Gardner says the plan picks up on the PCT’s wish to move care out of acute settings. “We want something that really meets local circumstances. We think we’ve got a solution and don’t want something imposed on us, which we might get if this was a pilot with one model.”
He sees the challenge as enabling relationships between managers, GPs, acute trusts and other partners to progress to a mindset where they can explore some of the possibilities integration could offer.
Great lakes: horizontal and vertical schemes in Cumbria
NHS Cumbria is testing two approaches to dealing with patients with chronic conditions. One is a “horizontal” scheme, integrating community services with around 20 general practices in an umbrella integrated care organisation covering 110,000 patients in South Lakeland.
The second aligns GPs and community teams around community hospitals, creating much smaller organisations with a “vertical ” element.
The South Lakeland scheme is based around a practice based commissioning group.
It will test the feasibility of setting up a healthcare management organisation-style structure in a rural location.
GP locality lead Hugh Reeve says the scheme is heavily influenced by Kaiser Permanente in Atlanta, which does not provide acute care, unlike Kaiser’s Californian operation.
The organisation will supply primary and community care and commission secondary care. Its ultimate aim is to help patients with long term conditions manage their own care better.
Dr Reeve says GPs facing the loss of historic income protection and changes to the quality and outcomes framework incentive scheme have embraced the idea of working together to test new structures.