Pioneering integrated care

Today 14 sites across England are to be named as ‘pioneers’ for integrated care. When I was on the panel interviewing the prospective pioneers in September, two things stood out: first, for a service caricatured to be demoralised, the enthusiasm, energy and sense of mission was startling. And second, the remarkable similarities in what they all wanted to achieve and why.

Most had successfully introduced small scale projects – typically for older people and those with mental health problems, and typically using proactive multidisciplinary teams. All wanted to expand these to transform care across the site (with populations from 150,000 to several million).

All had constructed governance and accountability arrangements involving NHS commissioners and providers, local authorities and linked in some way to the local Health and Wellbeing Boards.

All articulated barriers and wanted help to craft, for example:

• financial incentives for better outcomes (payment mechanisms and risk sharing arrangements)
• more intelligent contracts (eg using alliance contracts, lead provider contracts)
• linked datasets across providers (eg for risk stratification, monitoring use and costs across specific cohorts of people)
• testing of appropriate telehealth and telecare devices
• more impactful self management
• ways to involve public and patients more in designing coordinated care across different settings.

And all knew that, given funds and demand, there was no real choice but to attempt something radical whilst still doing the day job.

Delivery of such complex change is hard: grand plans often achieve disappointing results in the public sector. What might help this time? Here are a few reflections from evaluating previous, not dissimilar, initiatives…

First, recognise that no one really knows how to deliver complex change of the sort being pioneered. The conditions that made the small scale projects succeed may be completely different for other areas. Learn and adapt with staff and the public/patients, but particularly with other sites – pool intelligence (particularly with those which are failing) and correct the course.  

Second, lock onto the main objective: improving outcomes. This will motivate more people more intensely and for longer. There is a prevailing assumption that proactive and coordinated care will ultimately save costs. In Monitor’s recent Closing the NHS funding gap report, the savings assumed from integrated care were relatively modest, and evidence of the impact of similar initiatives worldwide is mixed.

Across the pond the pioneers’ namesakes – the 32 accountable care organisation pioneers – after their first year are showing (small) savings occurring in less than half. And this is relative to a traditional fee-for-service model where there’s likely more fat to cut than in the skinnier British model.

Third, focus on the bottom line: changing the practical delivery of care to improve outcomes for patients – not the construction of elegant contracting, payment, governance mechanisms, predictive risk modelling, however exciting. Measure progress in these terms.

Fourth, the prospect of more collaboration clearly energises people. Go with this drive. Put aside worries of developing cosy cartels of incumbent providers – aren’t there enough mechanisms to intercept this?

Fifth, a boring point but I must say it: invest in good project management. (Why is it so often limp?)

Like the rest of the country the pioneers will have equal opportunity to access the £3.8bn pooled budget (the Integration Transformation Fund) during 2015/16. But they will have four extra fillips: to join a learning collaborative of fellow pioneer vanguard sites; more access to national ‘partner’ organisations that can help them bust barriers to integration (like those mentioned above); some support for skills they’ve identified that they lack; and independent evaluation of progress.

Whether all this new effort will add up to transformation who can tell. But now must be a better time than ever before to try.

Jennifer is Chief Executive of the Health Foundation