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Commissioning: Integrated Care - Smoothing the patient journey

GP consortia should follow Lewisham's lead by commissioning care co-operatively.

Dr Fisher: 'In Lewisham, there are care pathway groups in areas such as COPD, urgent care, diabetes and anti-coagulation' (Photograph: Alex Deverill)
Dr Fisher: 'In Lewisham, there are care pathway groups in areas such as COPD, urgent care, diabetes and anti-coagulation' (Photograph: Alex Deverill)

Patients still find the NHS too disjointed. There are too many examples of poor internal communication, poor information transmission and poor links between parts of the system.

GP consortia need to ensure that the patient journey is smooth, efficient and that care is both effective and holistic.

One key impediment to integration is the contradictory incentives that make co-operation across this divide increasingly difficult.

Rebalancing the Market, a document published by the NHS Alliance in 2009, stated: 'Rather than providing incentives for acute and foundation trusts to collaborate with PCTs ...

Payment by Results (PbR) mechanisms discourage co-operation and can even result in inappropriate competition (or at least adversarialism) across the healthcare system.'


New opportunities
Under the coalition government, we have an opportunity to rearrange incentives to ensure they encourage NHS organisations to co-operate and to reward both quality and efficiency.

Specifically GP consortia should align finances where needed to incentivise quality, efficiency and co-operation. They should plan together with PCTs (while they still exist), local authorities, hospital specialists and local people. We need to use long-term condition (LTC) care pathways as the basis for this.

Primary care can do more outside hospital. Before the introduction of PbR, hospitals were generally happy to co-operate to reduce their workload, even if other forces militated against co-operation, such as empire-building.

In the current financial climate, however, it is no longer in a hospital's interest to enable fewer referrals, or reduce emergency attendances and admissions.

Service re-design often depends on action within secondary care, but that action may lead to reduced income through PbR for hospitals.

For example, if GPs need open access to diagnostics to avoid unnecessary hospital care, hospitals may have to commit more resources, or rearrange existing resources, to make this possible. But, if the desired result is achieved, demand for hospital care will decrease, reducing secondary care income.

Co-operative commissioning is one solution. This involves allocating joint (not pooled) budgets virtually across primary and secondary care, along care pathways, based on a programme budget approach. Currently every PCT has a moderately accurate set of programme budgets - this means the sums spent on areas such as orthopaedics, cardiology and so on.

Joint budgets
The task of GP consortia, local people and hospitals then becomes to manage that joint budget to maximise efficiencies and patient care. The incentive for everyone is that savings can be reinvested in the pathway, or elsewhere, as agreed.

For instance, in cardiology, the spend on heart disease would be seen as belonging to both consortia and local hospitals, akin to having a joint account. If savings are made through more efficient care pathway design, then the savings can be shared. If fewer patients come through the hospital's doors, it can still gain if savings are made.

It would become a joint task to ensure that patients received treatment in the most cost-effective way. For many LTCs there are evidence-based interventions that reduce outpatient and A&E attendance, including providing information on self-care and prevention.

There would be an incentive for hospitals to invest in these as well as primary care, and enthusiasm for co-operation in A&E as savings there would mean more joint benefit.

DoH guidance
To back this there is a clear set of guidelines in the 2005 DoH Programme Budgeting Guidance Manual (for the programme budget marginal analysis process) enabling commissioners to begin to answer the following questions:

  • Are health outcomes better or worse than higher-spending areas?
  • Where would investment generate greatest return?
  • Are there areas of expenditure where we can get better outcomes per £1 spent?

In this way, incentives for efficient care are retained, but the planning and investment becomes a shared enterprise.

NHS staff should leap at this chance to work together again in a shared enterprise. This, in a different context, is one of the ways in which Kaiser Permanente - the US health maintenance organisation - achieves excellent cost-effective outcomes.

There are many possible complexities with commissioning pathways from different hospitals, such as deciding how to divide savings between primary and secondary care, dealing with pathways and incentives at different levels, tertiary care and so on.

However NHS Lewisham, south-east London, is taking this idea forward. Lewisham commissions all of University Hospital Lewisham's (UHL) care. The PCT has developed care pathway groups in areas such as COPD, urgent care, diabetes and anti-coagulation.

UHL consultants and other hospital clinicians work with GPs and relevant community staff. Starting with the agreed budget, their task is to take out inefficiencies in the system and deliver savings and disinvestment where needed.

We have an agreed process for sharing savings and working at different levels in the local health economy and pathway tariffs are being explored.

We do have one advantage: UHL is the new provider of community services. This means that, if services are pushed into the community, UHL stands to lose less than if it were solely providing hospital services.

  • Align primary and secondary finances where needed to incentivise quality, efficiency and co-operation
  • GP consortia, PCTs, the local authority, hospital specialists and local people to plan together
  • Use long-term condition care pathways as basis for integration
  • Include local people's involvement
  • Create new structures only when needed
  • Consider new roles where needed
  • Integrate shared information systems between patients and professionals.

Dr Brian Fisher is a GP in Lewisham and Patient & Public Involvement Network Lead for the NHS Alliance

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