Ministers are planning to support a series of large-scale, locally led “experiments” in integrated care that could enable commissioners to move away from the payment by results tariff system.
In an exclusive interview with HSJ, health minister Norman Lamb said he wanted to encourage organisations to set up integrated systems, and to ensure that the Department of Health “facilitates” any such attempt.
Although both he and health secretary Jeremy Hunt have previously spoken about the need for more integrated services, this is the first clear indication of how ministers plan to make widespread integration a reality.
Mr Lamb convened a roundtable meeting at the King’s Fund in London earlier this month to discuss integration. It was attended by Monitor chief executive David Bennett and representatives of the NHS Commissioning Board, local government and patient groups.
King’s Fund chief executive Chris Ham, who was present, said support from the government could involve explicitly allowing health economies to devise their own payment systems so they moved away from payment by results.
The government could also play a role supplying practical support, or in providing assurances that Monitor will not act to break up collaboration.
By spring next year, Professor Ham expects the DH to set out how it will enable changes to payment systems and regulations to be made, possibly taking bids from interested areas and “designating” around 10 places to proceed. He added: “Norman wants to be the minister who makes it happen.”
Mr Lamb is keen to enable local “experimentation” rather than dictate how integration should be achieved. “We will move quickly to give clear guidance to people about how they can best deploy their skills to make it happen,” he said.
“If a group of primary care, secondary care and social care partners say that with a capitated budget approach they can create incentives to maintain the health of the population better, to reduce the number of people unnecessarily going to hospital, the system ought to allow that to happen.”
Mr Lamb is keen to avoid a lengthy process of piloting and then rolling out integrated systems. “I don’t think it has to take ages,” he said. “[We must] get across the message to the whole system from the centre that this is enthusiastically embraced and encouraged.”
Despite fears that Monitor’s duties as an economic regulator could force it to break up anti-competitive integration, Mr Lamb said the body’s leadership was committed to the plans. Monitor “is not going to be a zealot promoting competition for its own sake,” he said.
Mr Lamb also pointed out that the commissioning board’s mandate gives it an “obligation” to drive integration “at scale and with pace from April”.
His comments were widely welcomed, although some pointed out integration could be achieved through local moves, regardless of action from the centre.
Yi Mien Koh, chief executive of north London’s Whittington Health Trust, said political support for integration was “helpful”, but she emphasised the importance of providers and commissioners being willing to share both responsibility and risk.
Dr Koh’s trust already holds a capitated contract. This means it delivers acute and community services funded on a basis of population rather than episodes of care. She said the arrangement now needed to go “sideways”, to facilitate work with neighbouring trusts with whom the Whittington shared patients.
“Being designated as an experiment would make people freer to make things happen,” she said. The trust “would love to be part of one of [Mr Lamb’s] large experiments”, benefitting from “practical support from the DH”.
Peter Melton, accountable officer of North East Lincolnshire Clinical Commissioning Group, also said he would like his organisation to take part in one of the experiments. “Certain populations − such as the frail elderly and people in the last year of life − need primary care, secondary care and social care working together. Sometimes the tariff works against you trying to achieve that.”
He said he would like to be able to increase the size of commissioning for quality and innovation payments, and have more determination over their use in order to bind providers to common objectives.