Senior Fellow, Health Policy
Nick's work interest in healthcare policy and management spans 20 years and a varied portfolio, including the organisation and management of primary care, commissioning and integrated care. Nick is a Fellow of the Royal Geographical Society and a lapsed sportsman and armchair explorer. He is happily married with a beautiful one-year-old daughter
Who hasn't listened to tales of interminable journeys from one doctor to another: the wait for appointments, referrals, and test results? Most of us will know of a friend or elderly relative who has been diagnosed with one or more serious conditions, yet are seemingly left to their own devices without adequate professional support when at their most vulnerable.
The characteristics of poor integration are easily recognisable, and yet fragmented and badly co-ordinated services continue to pass patients from "pillar to post" around the system. The duplication or, worse, omission of important parts of the care process can lead to poor patient care, and communication between patients and their care providers could be so much better.
The fact is that in our "modern" NHS, we are beginning to forget that a high-quality service should emphasise proactive care co-ordination – particularly as most patients would almost certainly benefit significantly from such care. With an ageing population and the ever-increasing prevalence of both chronic and long-term illnesses, a challenge has been established for the fostering of new forms of clinical and interorganisational partnerships and networks and the promotion of care support strategies within the home environment.
The urgency of making this shift in the balance of care settings is being driven by the dramatic upward trend in costs. If we do not engage with keeping people healthy, independent and out of institutional care (both long-term care and hospital care) then total expenditures will rise to potentially unsustainable levels as utilisation rates increase exponentially.
What do we mean by "integrated care"?
The primary purpose of integrated care is really very simple: to improve the quality of patient care and patient experience and increase the cost-effectiveness of care through co-ordinated care delivery across multiple services, providers and settings.
To achieve this, however, is very difficult: a coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels have to be designed and implemented. Where the result of such efforts leads to the benefit of patient groups, the outcome can be called "integrated care".1 The inherent hypothesis is that more integrated care is good for patients and better value for money.
Barriers to integrated care
Despite our ability to recognise and articulate the problems that patients face when the health system fails to connect together, the solution – "we need more integrated care!" – is a mantra that has repeatedly failed to be translated into positive action.
A recurrent theme in policymaking in the NHS is an exhortation of the need for greater "collaboration" to achieve "co-ordinated", "seamless" or "integrated" care that is "patient-centred". Despite some successes, mainstream NHS services have remained steadfastly resistant to the call.
Barriers to achieving integrated care are too numerous to list here in full, but I will attempt to highlight some of the major ones to paint a picture of why it has been so problematic.
First off, it is abundantly clear that few policymakers or professionals really "get" integrated care, and there is a lack of common understanding of what it really means. Commentators have observed how it comprises a bewildering array of vague and confusing terms – a "quagmire of definitions and concepts" or "a confusion of languages akin to the biblical Tower of Babel".(1,2)
A second key problem is that the consequences of integration are rarely beneficial for all parties. So when it comes to the crunch, the protectionism inherent in competing professional tribes will, more often than not, regard integration as a threat to be countered rather than an opportunity to be embraced: "Your integration is my disintegration".(3)
The ability to counter integration is aided and abetted by the inbuilt inertia to change within our Byzantine health and social care system and silo-based culture of working. Moreover, where integration is pursued, it often becomes a process-driven exercise in "change management" or "organisational redesign" – any benefits to patients at the end of the exercise can become secondary, or lost altogether.(4)
There is also a more pressing question here: what is the business case for change? One of the enduring laws of integration is that it requires upfront investment (and organisational upheaval) before results accrue,(3) yet in most cases it is impossible to articulate a definitive return on this investment. Combine these problems with a risk-averse NHS and a cold financial climate, and it becomes understandable that embracing any such change is problematic.
General practice, PBC and ICOs
Over the past few years, the preferred vehicle for delivering integration between primary care and the wider health service has been practice-based commissioning (PBC). PBC was intended to ensure that care was organised around the individual patient by building commissioning responsibilities onto the existing role of general practice.
It was also meant to encourage health promotion, the co-ordination of care to those with long-term chronic illness, and ultimately to avoid costly hospital admissions. The incentives in PBC were meant to enable collaboration between GPs, community services and social care.
PBC, however, has to date not addressed such strategic concerns and has been acknowledged as a failing policy in need of reinvigoration.(5,6) Despite the apparent advantage in having an established network of general practices to provide comprehensive care to a registered list of patients, it has proven problematic for the system to embrace multidisciplinary working and proactive care management.
It is true that the Quality and Outcomes Framework has led to changes in GP behaviour through rewards for meeting quality standards in the care and management for people with chronic conditions, but on the whole practices remain isolated from other care providers.
For this reason, policymakers in England have recently introduced a new concept, that of the integrated care organisation (ICO), in an attempt to encourage GPs to work collaboratively with other clinicians to take responsibility for the design and delivery of integrated services. It has been specifically promoted as the next step in the evolution of PBC, since:
"[PBC] will only reach its full potential – and grow more naturally into ICO-type models – if it brings together a range of clinicians including community nurses, allied health professionals, pharmacists and secondary care clinicians and secures strong relationships with social services." (7)
ICOs are intended to be a means for integrating the work of general practice with primary and secondary care clinicians, community nurses, allied health professionals and social care workers through "clinical collectives".
A first wave of 16 ICO pilots went live on 1 April 2009. These pilots appear to vary significantly in their scale and scope – eg, in the range of services involved, the size of their consortia, and the size of the population they serve.(8)
The ICO pilots have different objectives. Some concentrate on selected conditions (such as diabetes), some on client groups (such as older people), and others seek a system-wide integration of payer and provider functions across a whole health economy – a fully "managed" system.
This latter form of ICO is a potentially radical innovation, but appears to be gathering momentum. The approach raises the prospect of large, professionally-led, multipractice PBC clusters acting as a key staging post for the creation of ICOs.
Participating practices might work within a global capitated sum for each patient on their list – or even to a list linked to the ICO as a whole – and assume responsibility for co-ordinating access to all necessary care. This would require ICO management to decide which services to provide themselves and which to commission from other organisations.
Crucially, professionals working in such ICOs would take responsibility for some or all of the "risk" in managing budgets, potentially sharing rewards if this is achieved successfully, as long as specified quality and patient experience standards set by the primary care trust are met.
How might ICOs operate in practice?
There is no prescription for how an ICO might operate in practice. In theory, the ICO could be established through an "any willing provider" contract with PCTs, opening the way for the commercial sector to enter the market through managed care companies such as UnitedHealth or McKesson.
In reality, however, most ICOs will be created among collectives of GP practices with whom patients would be registered. The ICO might then take on responsibility – under contract with a PCT – for supplying a range of services directly and/or by subcontracting with other independent providers on behalf of their patients. Governance and risk-sharing relationships are likely to develop between PCTs and ICOs to ensure quality and budgetary targets are met.
The organisational structure of the ICO itself is likely to vary by local circumstances and the legacy of previous associations. For example, options might include:
There is no single vision for how ICOs might develop. Many will emerge from PBC and develop organisations based on a registered list of patients, but it's also highly likely that others will be "commissioned" on an any willing provider basis. Some will seek to provide comprehensive services, yet others may specialise in the management of a particular disease.
While the piloting of ICOs may shed some light on "what works", the likelihood is that ICOs will emerge in an unplanned fashion and come in all shapes and sizes.
This leads to a paradox one might call the "disintegrated integration syndrome" – where the jurisdictional and organisational barriers to integrated care that existed in a previous system are replaced by an entirely new set of arrangements that are themselves dysfunctional, albeit in different ways.
Will GP practices really evolve into ICOs?
It is 150 years since Charles Darwin's On the Origin of Species provided a step-change in our understanding of the building blocks of life. Despite the subsequent weight of evidence (from the fossil record to the discovery of DNA and the mapping of the human genome) that prove conclusively that all life on earth is inter-related, nearly half the world's population deny it to be true – with or without "God's guidance".
There is, of course, no accepted evolutionary theory for general practice. While belief in integrated care as a concept is widespread, there is far less evidence for it than can be said of Darwin's theory. Hence, despite the ultimate strength of the rationale for pursuing its aims (which seems undeniable – at least to me), decisive action that might see general practice make a step-change of its own would seem unlikely.
Nevertheless, for the foreseeable future, it is highly probable that ICOs will be promoted and that some practices working in large PBC clusters will become integrated into the ICO approach. Most of these will probably evolve as a symbiotic relationship – practices working with partners in some form of "federated model" (like that envisaged by the Royal College of GPs) and so retain and defend their independence while contributing to a "common good". A few practices may ultimately become part of entirely new forms of organisation – potentially as partners and/or leaders in their operation. Yet others, of course, will remain isolated and distinct.
Of course, whether such efforts will really mean better integrated care for patients remains to be seen. Whatever the future, the ability to prove that the quality of patient care and patient experience has improved – and the cost-effectiveness of the system increased – should remain the touchstones by which future iterations of general practice, PBC and ICOs should all be judged.
1. Kodner D, Spreeuwenberg C. Integrated care: meaning, logic, applications and implications – a discussion paper. International Journal of Integrated Care 2002;2(3). Retrieved January 21 2009. Available from: http://www.ijic.org
2. Howarth M, Haigh J. The myth of patient centrality in integrated care: the case of back pain. International Journal of Integrated Care 2007;7(3).
3. Leutz, W. Five laws for integrating medical and social care: lessons from the US and UK. The Milbank Memorial Fund Quarterly 1999;77(1):77-110.
4. Goodwin N, Shapiro J. The road to integrated care working. Health Services Management Centre, University of Birmingham; 2001.
5. Curry N, Goodwin N, Naylor C, Robertson R. Practice-based commissioning: reinvigorate, replace or abandon? London; King's Fund: 2008.
6. Department of Health. NHS Next Stage Review: our vision for primary and community care. London: Department of Health; 2008.
7. Department of Health. Clinical commissioning: our vision for practice-based commissioning. London: Department of Health; 2009.
8. Department of Health. Launch of Program of Integrated Care Pilots. London: Department of Health; 2009.