Dr Gerard Panting outlines the concept of integrated care, and the benefits and challenges that it may bring, along with details of the Department of Health pilot programme
A recent review of practice-based commissioning (PBC) by the Audit Commission found little evidence of GP practices and PCTs providing care in conjunction with public health, local authorities, and other agencies, in line with the vision of service change outlined by the Department of Health (DH).1 Integrated care organisations (ICOs) offer an alternative, if unproven, way forward, and in 2008, the DH reported in its Next Stage Review that it would be launching an integrated care pilot programme.2
In response to the announcement of this programme, the DH received a total of 108 applications by the November 2008 deadline. This figure has now been whittled down to 37 bids covering all English strategic health authority regions involving partnerships with social care, secondary care, and the voluntary and private sectors. According to information from the DH, the applications cover a wide range of healthcare categories, including:3
- long-term conditions
- care of older people
- urgent care
- mental health
- children’s services.
The 37 short-listed bids will undergo a further rigorous assessment before final selection is made at the end of March 2009. The finalists will then operate for 2 years and will be evaluated over 3 years,3 so it will be 2012 at the earliest before it is known if ICOs are to become a standard part of delivering services to NHS patients.
What is integrated care?
There are numerous definitions of integrated care; for example, the DH describes it as:2 ‘… GPs, community nurses, pharmacists, social care teams, ambulance services, schools and others coming together on a collaborative basis with clear leadership, shared goals and shared information — and designing services around the needs of individuals and local communities.’
In essence, integrated care is the provision of comprehensive care for specific groups of patients who have chronic conditions ranging from atrial fibrillation to alcohol dependence. As pointed out by the DH, an integrated approach does not necessarily mean providing care in a single building or within a single organisation.2 The aims are to deliver better services across primary, secondary, and social care in an economic manner, and improve the standard of overall care for specific groups of patients.
Examples of organisations that can participate in the provision of integrated care are listed in Box 1.
Integrated care in practice
Integrated care is already offered to specific groups through integrated networks,4 but the new proposal and pilot take the proposal one stage further, with the creation of new organisations providing primary and community care enhanced by specialists and social care.5 Community-based ICOs will have their own funding and management support, but will be clinically led. Primary care trusts will remain responsible for commissioning care to the required standard, but ICOs will have the freedom to develop new methods of delivering care without reference to commissioners, provided that quality is maintained. These schemes could, therefore, herald a new approach to commissioning, in which primary care trusts pay for outcomes rather than services. This in itself is a significant development.
Details of the 37 shortlisted ICOs will not be published until March 2009, however, examples of some of the proposed bids include:6
- a scheme to improve diabetes and end-of-life care for a population of more than 170,000—through the integration of primary care, community services, and an acute foundation trust, with support from the private sector
- a programme to integrate mental health and well-being services for people of working age—the proposed partnership includes a PBC consortium, PCT, mental health trust, local authority, and communities
- ‘health maintenance organisation’ services run as a social enterprise by a not-for-profit community interest company.
Potential advantages of integrated care organisations
There are a number of advantages that ICOs could bring to healthcare delivery:
- evidence from the US has shown that it is beneficial to align incentives for clinicians with those of healthcare organisations (focused around patient experience and population outcomes) (pers. comm)
- integrated schemes provide access to the broadest range of clinical and social-care expertise, coordinated to provide higher standards of care more efficiently, making the most of the combined skill sets and avoiding un-necessary duplication
- integrated care offers the opportunity to remove some of the commissioner–provider tension in PBC
- the concept of integrated care offers greater freedom to develop innovative care tailored to the particular needs of the patient group, while taking into account important local factors that may not be mirrored elsewhere.
The range of organisational structures likely to emerge from this DH initiative may be as broad as the clinical conditions addressed by the ICOs. At one end of the scale there may be ICOs that both commission and deliver services to patients, and at the other, organisations that deliver no care themselves but enter into long-term contractual relationships with providers including those from the independent and charitable sectors. In rural areas particularly, the options may be limited to a realignment of existing providers providing a more seamless approach to care.
There are a number of challenges that will need to be addressed quickly if the pilots are to proceed on schedule. These include:
- a change of culture and the will to undertake this work within the partner organisations
- the short timescale
- developing a new budgetary system
- creating the necessary governance and management structures
- putting risk management in place
- maintaining patient choice
- evaluating the outcomes effectively
- establishing dispute resolution procedures
- providing IT support.
These challenges are capable of causing significant headaches for those at the helm of ICOs. From the political perspective, maintaining choice has the potential to grab the headlines. Choice cannot exist where patient volumes are low and other providers too far away to be realistic alternatives, however, it should be maintained where possible as competing groups are seen as a major driver to improve standards of care.
The roll out of ICOs across England is still a number of years away, and results from the relatively small number of pilots will not be assessed until 2012 at the earliest. They hold the promise of a more effective way of managing chronic conditions, especially where medical and social components are intertwined, but there are also a considerable number of obstacles that will need to be overcome during their implementation.
Box 1: Organisations/groups that can contribute to the provision of integrated care2,4
- Audit Commission. Putting commissioning into practice. London: Audit Commission, 2007. Available at: www.audit-commission.gov.uk/reports/
- Department of Health. High quality for all: NHS Next stage review final report. London: DH, 2008. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825
- Department of Health website. Integrated care: Integrated care pilots. www.dh.gov.uk/en/Healthcare/IntegratedCare/index (accessed 5 January 2009).
- Lloyd J, Wait S. Integrated care: A guide for policymakers. London: Alliance for Health and the Future, 2006.
- Department of Health. Integrated care pilot programme: Prospectus for potential pilots. London: DH, 2008. Available at: www.dh.gov.uk/en/Healthcare/IntegratedCare/DH_091112
- Health Service Journal Website. More than 100 step up with integrated scheme bids. www.hsj.co.uk/news/2008/11/dh_deluged_by_more_than_100_ico_pilot_applications.html (accessed 12 January 2009).G