Strategy will knit up the ravelled sleeve of care

The primary and community care strategy published as part of the NHS next stage review highlights the need for more integrated care. For all its strengths, the NHS at times struggles to co-ordinate its constituent elements into a coherent whole.

International surveys testify to the fact that poor co-ordination of care is prevalent worldwide: a fault line running through many health systems. Since patients need care that often transcends traditional institutional healthcare boundaries, this is a significant challenge.

For patients the result of this lack of integration can be confusion and poor quality care; a service that is less than the sum of its parts. The consequence for wider health services can be overuse of hospitals, or duplication or omission of important components of care.

The new strategy focuses on many solutions to the integration problem, including new clinical roles charged with care co-ordination, a stronger emphasis on individual care plans and better IT that enables services to communicate. It also introduces pilots designed to take integrated care to a new level.

A number of integrated care organisations are to be tested across the health service in carefully evaluated pilot sites. These pilots will explore new models for delivering integrated care to defined populations. They will use NHS resources to secure services for patients, developing care pathways that cross traditional institutional boundaries. They will choose whether to provide all of the pathway themselves (for example, by incorporating different clinicians within their teams) or to subcontract provision to others. They could be seen as supercharged practice based commissioning.

Primary care trusts will hold the organisations to account through contracts that specify patient outcomes wherever possible; in particular, contracts should target outcomes that can best be delivered through a whole pathway of care. This will include accountability for delivering better health as well as better health services. This contrasts with the current system, where PCTs largely contract for different components of a pathway, usually from different providers and with a focus on activity rather than the resulting health improvements.

While GPs are used to taking responsibility for providing primary care for registered populations, integrated care organisations will extend that responsibility to a wider range of care. In some cases this could include most care required by the population. The integration these pilots will promote can be vertical (between primary and specialist care) and horizontal (knitting together primary, community and, increasingly, social care).

In theory, ensuring a single point of responsibility backed with a firm budget will give providers a stronger incentive to develop services that fit around the patient rather than the requirements of disconnected providers. Moreover, by giving such an integrated organisation a single budget to cover care normally provided across primary and secondary care, a better balance between investment in treatment and in prevention should be achieved.

Perverse incentives

These pilots should be clinically led and could involve a wide range of disciplines, including consultant specialists and primary, community and social care professionals. By putting the available resources in the hands of a broad clinical team, new pathways can emerge that challenge existing working patterns where these do not benefit patients.

A budget that is held by a broader based clinical team should also resolve some of the current perverse incentives; for example, where specialists may be under pressure not to collaborate with primary care teams because resulting reductions in avoidable admissions would result in a loss of hospital income.

These pilots have similar characteristics to the best managed care organisations in the US. In particular, they will share a focus on multi-specialty clinical partnerships, a rigorous approach to quality management and an emphasis on disease prevention as well as treatment. But they will need to adapt to a very different environment.

In the US, managed care has been characterised by significant choice for patients from among competing managed care plans, but sometimes a restricted choice of care provider. For example, in California members of Kaiser Permanente plans are only permitted to use in-house services.

The English context is rather different. Here, patients are guaranteed choice of provider at the point of referral for specialist care and there is a commitment to extending choice into the care of people with long term conditions. Conversely, choice of registration with general practice (from among which some of these pilots are likely to emerge) is sometimes limited.

So while international experience may offer useful insights, we need to build a uniquely English vision for integrated care.

If innovation and service quality are to flourish, clinical engagement is vital. But integrated care organisations must not become clinical dictatorships, however benign. PCTs have a crucial role in holding them to account and in ensuring the interests of both public and patients are served.

Patient choice must also play its part in holding them to account. Evidence from the US suggests a competitive environment plays a part in keeping the best managed care organisations on their mettle.

But choice may be limited in parts of the English health service as these organisations may be formed by the majority of general practices in a local area - good for clinical collaboration, not so good for patient choice. Here, decisive commissioning by PCTs will be vital and trusts may wish to ensure that, where patient choice is limited, patient and public engagement is strong.

Of course, some will be tempted to see this initiative as the precursor to further structural reorganisation to be imposed by the centre. In truth, these organisations may not be formal at all, but rather alliances of like-minded teams coming together for the common purpose of delivering more integrated care. Successful integrated care organisations will be driven by clinicians and managers locally and will evolve differently according to prevailing circumstances.

There is unlikely to be a single "right" way to integrate services. The pilots provide an opportunity to test different models and a safe framework for those prepared to undertake radical innovation.

The programme will be driven forward by Department of Health director general of commissioning and system management Mark Britnell, and applications will be sought later this year.

Questions remain

A number of challenges still need to be addressed if these pilots are to be successful and to pave the way for a radical and sustainable reform of healthcare delivery.

First, integrated care demands much more from clinicians and managers. Clinician-driven organisations especially will need to cope with the clinical and financial risks associated with budget holding for registered populations. Given that many of these organisations are likely to evolve from within primary care, there is a steep climb ahead if managerial capacity is going to be sufficient to deliver the ambitions. Lessons from overseas suggest a bigger investment in management infrastructure will be required.

Second, the information requirements of integrated care will be testing. Co-ordinating information across primary, secondary and social care systems will be essential to support integrated clinical care and to measure results. To date, this has not been a strength of our system.

Third, funding methodologies will need to evolve quickly to ensure the new incentives work well. While capitation funding is likely to be preferred, this will need careful calibration if the organisations choose not to take on responsibility for the full range of services. Moreover, any funding formula must be highly sensitive to patients' risk profiles if "cream skimming", where organisations seek to register the less sick, is to be avoided. More information will be needed to judge the minimum population size at which financial risk can be effectively managed and how risk sharing arrangements can be developed.

Last, commissioning capability will need to be high if public and patients' interests are to be secured in the face of stronger supply-side incentives.

Getting the balance right will be crucial. PCTs will need the confidence to give sufficient freedom to the integrated care organisations to innovate, but strong enough accountability to ensure the delivery of the desired outcomes. PCTs will also have to act as choice regulators, ensuring patients are free to choose and are not simply railroaded into the organisations' in-house options.

Health minister Lord Darzi made clear his review is intended to be "enabling". The real work of delivering change on the ground lies with clinicians and managers at the front line. Integrated care organisations will undoubtedly challenge traditional thinking about how services can be delivered and early indications are that many are ready for this opportunity.

See A look inside a care trust plus for more.