How can primary care organisations and hospitals ensure effective integrated care? Donald Light and Michael Dixon suggest collaborative contracting is the key

Patients with serious health problems would like nothing better than integrated care that will manage their sickness and keep them out of hospital. Indeed, 'intermediate care' between the hospital and primary care is now being flagged as a way to modernise the old, hospital-centred NHS. The question is how? We suggest a practical answer, a tool for primary care organisations contracting for secondary care, and a new way forward for consultants.

The prospects for intermediate care depend on primary care organisations' ability to develop intermediate services with specialists, or integrated care programmes that maximise patients' capacities and keep them out of hospital. Yet this policy goal, and how to achieve it, are still not clearly perceived. A recent survey of 60 primary care groups and primary care trusts revealed that the single greatest obstacle to change was perceived as obstruction from acute trusts and specialists.

If the first level of a modernised NHS is empowered patients who help to manage their health and health problems, then the second is expanded primary care and the third is not the hospital, as health secretary Alan Milburn put it.

Instead it is community-based collaborative services between primary and secondary care teams for these costly and vulnerable patients.

Such services might involve the development of 'community resource and treatment centres' from community hospitals, some nursing homes or from other Acute hospitals must increasingly become the fourth level of care in a modernised NHS.But is the NHS Executive ready to do it? This is a core problem of national leadership being both commissioner for value and modernisation, and provider.

The core problem is financial. Budgets for developing integrated intermediate care services are tied up in the hospitals, and numerous government conventions lock in these budgets.

As well as the perverse incentives that Mr Milburn identified as lengthening waiting times for elective surgery, budget barriers create 'blocked incentives' to costeffective care. Blocked incentives are responsible for unnecessary referrals and admissions to hospitals, clogged waiting lists, poor discharge and hand-over back into community care, and underdeveloped intermediate care.

Take, for example, a hospital with a£50m budget. If all its unnecessary hospital admissions and occupied beds per day could be reduced by a quarter, the hospital would simply redivide the£50m.The conclusion would be drawn that its costs for each remaining occupied bed per day had risen by a third more than before.

Consultants have been protected by this historical arrangement, but increasingly they are trapped by it. A managerial superstructure has developed around them, and they find themselves helpless as more and more patients are referred to them.

A significant proportion of these are unnecessary, and another significant proportion could be avoided if only specialty teams could give primary care teams a bit of training.

Hospital admissions keep rising 3.5 per cent a year, and 60 per cent of total admissions are now 'emergencies'; yet there is no epidemiological justification for these high rates. The national beds inquiry found 'significant inappropriate or avoidable use of acute hospital beds'.

Collaborative contracting (see below) holds the key to overcoming budget barriers and aligning the interests of consultant-led specialty teams and primary care teams. It gives enlightened consultants the ability to develop an integrated service that minimises the number of patients who need sub-specialty services and costly procedures by developing community-based nursing and related services.

It gives primary care organisations the tool for defining and sharing a budget and an agenda with consultant teams, to provide prompt integrated care to patients at lower costs. The collaborating parties share and divide the savings so that both gain new funds to develop integrated services even further. Specialists and primary care clinicians are required to develop integrated care across traditional sectors so that sick patients are not treated at the wrong time and in the wrong place because of blocked incentives to do things right. Assuring clinical excellence both in primary and specialty care is also facilitated by the collaborative contract structure.Collaborative contracting aligns financial interests, rewards both consultants and primary care organisations, and spans current budget barriers.

One of the great strengths of primary care organisations is that health service planning can be done by those also intimately involved in seeing those plans carried out.

Future PCTs might have clinical directorates for the common specialties, led by a clinical director, who might be a specialist, GP or nurse.

The clinical director would be responsible for making sure plans were effectively implemented, blocks removed and relevant targets and outcomes achieved. The result should be a fully integrated, fully owned and full collaborative service that might for the first time bridge primary and secondary care.

Modern, integrated services involve three changes: refocusing services on what patients most need to maximise their functioning and well-being, increasing the role of nurse specialists and reducing the need for hospital services.

Collaborative contracts are a tool for primary care organisations' purchasing of secondary care, and would transform waiting lists from unco-ordinated patterns of referrals and consultations to an integrated system of referral, investigations and treatment. Both primary care professionals and consultants would gain from swift and appropriate care for their patients. The new NHS needs to start collaborative contracting pilots for integrated intermediate care as soon as possible .


1 Milburn A. Shaping the Future NHS: long-term planning for hospitals and related services (foreword). Department of Health, February 2000.

2 Dixon M. Should The NHS use Nursing Homes? Cullompton, Devon, April 2000.

3 Implementing the Vision: maintaining the values. NHS Alliance, 2000.

4 Light DW. Effective Commissioning. Office of Health Economics, 1998.

How collaboration works Identify the patients of the target group (be it patients with cardiac or mental health problems or some other area), the services now being given by the consultant team, hospital services more broadly, community nursing, and primary care teams.

Clinical criteria will involve the parties in valuable dialogue about their different perceptions and approaches.

Identify costs related to these services, including administrative costs. These will constitute the budget the partners will hold jointly. This will require the collaborating parties to discuss how they will calculate costs, perhaps with the health authority and the NHS regional office.

Given the inadequate data on most NHS clinical services, this process could take months and cost thousands of pounds as hand-written calculations are made from original clinical paper files. But reasonable estimates can move the process along, and they will work so long as the contract recognises them as firstorder estimates, to be adjusted.

Establish a jointly held clinical and financial data system. This is the core weakness of the NHS, which is in its 10th year as a purchasing-oriented system yet still has no data system to track quality and cost-effectiveness.

Develop a flexible care pathway, with options for informed choices reflecting individual circumstances.

Involve patients and all professionals.

Draw up a contract for services. Specify joint plans for reducing hospital admissions, length of stay and specialty visits. Draw up complementary plans for minimising waits. Set limits on losses and develop backup arrangements for failures. Divide savings, perhaps 30 per cent to each collaborating group, 20 per cent for administration, and 20 per cent for evaluation. Start-up money may be needed for collaborative contracting groups, and the government might (or might not) want this money returned in the first five years of operation.

A critical part of this phase is agreeing and disseminating clinical criteria for treatments and referrals, which are owned by both primary and secondary care. These will incorporate national guidelines, such as the National Institute for Clinical Excellence, where appropriate. The structure for clinical and financial governance will need joint agreement.

Key points

The development of intermediate care, which will keep patients out of hospital, depends on co-operation between specialists and primary care organisations.

Community hospitals and some nursing homes will have to take on new roles as community treatment centres.

Action is needed to unlock budgets currently tied up in hospital services.

The potential for consultants and GPs to work together to commission services needs to be unleashed.

Clinical criteria should be established for referral to these services.