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All things Pharma

Being closer: Integrated integrated care

Alan Jones looks at the latest integrated care programme. Can the boundaries between primary and secondary care really be broken? How will this impact the way pharma reaches its customers?

Many of the NHS intiatives written about this year stem from the English Darzi Next Stage Review. Readers may know that a Primary and Community Care Strategy was published separately to High Quality Care for All and this strategy proposed a refocus on the integration of services across the various sectors. A number of integrated care pilots (ICPs) would be set up to explore different ways in which health and social care could be provided. However, please note that integrated care is not so new. This has been the model in Northern Ireland for many years and now Scotland and Wales have following suit. There is also a long established Journal of Integrated Care. And, of course, many companies have done a lot of work around integrated care pathways and service redesign over the years. What is new is integrated, ‘integrated care’, as there is no doubt that the establishment of a managed market has fragmented care and possibly opened up brand new divisions within the English NHS.

Amongst a number of other initiatives over recent years to try and bring health and social care closer together in England are the Care Trusts. They were introduced in 2002 as pilots and at the time were seen to be the successors to PCTs, as they themselves were to PCGs. However, forcibly throwing together health and social care in this way proved to be a step too far. In the main, this organisational solution was largely resisted by the local NHS as it was just too difficult – it was also voluntary. So some seven years on that’s still where we are today – just a few ‘pilots’, now referred to by the Department of Health as ‘demonstrator sites’. They are, however, important to know about, especially for those working in these particular local health economies. They have either focused on a model where a PCT merges with local social services (e.g. Bexley) or a mental health trust (e.g. Sheffield) doing the same. Care of the elderly, mental health, disability and children’s services tend to be their main focus. Note that their governance means that local authority (elected) councilors are members of the board.

The Integrated Care Pilots

Moving forward to the latest ‘experiment’ we see that some 16 Integrated Care Pilots went live in July this year, some big (Norfolk), some small (Church View). The aim of this new two-year programme is to try and transform the way people experience health and social care. The pilots will be evaluated over three years against a set of national and local measures.

There were initially over 100 applications and a further shortlist of 37. Note that three SHAs (South Central, South East Coast and West Midlands) do not have any and North East SHA has three. The £4m scheme is designed to look beyond traditional health and social care boundaries to explore how services for patients and service users can be improved and will assess the benefits of different models of care and identify any best practice that could be used more widely. Most involve a focus on long-term conditions, care in a community setting and reducing hospital admissions. The pilot sites involve partnerships of primary care with social care, secondary care, voluntary and private sectors and the health issues being tackled by pilots include dementia, care for the elderly, substance misuse, COPD and end of life care. Please see the table for fuller details on all the pilots.

The methods involved vary widely. These include partnerships, new systems and care pathways that span primary, community, secondary and social care and involve both ‘horizontal’ and ‘vertical’ links. Six of the sites have been selected for deeper (‘deep dive’) evaluation by independent external evaluators and their impact will be measured on improving the health and wellbeing of their local populations – so that’s on health outcomes, improved quality of care, service user satisfaction, and effective relationships and systems. The idea is that extensive data collection will add to the evidence base for the further future integration of care. See www.dh.gov.uk/en/Healthcare/IntegratedCare/ and for a short film on the pilots, see www.youtube.com/wcccomms.

Summary of the Integrated Care Pilots

Name Area of Focus

Bournemouth and Poole Teaching PCT New model of care for older people with dementia

Cambridge Assura LLP End of Life care

Church View Medical Practice Older people with long term conditions

NHS Cumbria Chronic disease management

Durham Dales Integrated Care Organisation Health inequalities in a rural population

Nene Commissioning CIC Long terms conditions and end of life care

North Tyneside Falls prevention in the over 60s

Cornwall & Isles of Scilly PCT Dementia services

NHS Norfolk and Norfolk County Council Care of the elderly

Northumbria Health Care NHS Foundation Trust Self management of COPD

North Cornwall PBC Group Mental health integration

Principia – Partners in Health Self management of COPD

NHS Tameside & Glossop Cardiovascular disease risk management

Torbay Care Trust Care of the elderly

Tower Hamlets PCT Chronic disease management

Wakefield Integrated Substance Misuse Service Social reintegration

But note that their reception has been mixed. In order to really break the boundaries between primary and secondary care, the NHS Alliance believes any further wave of Integrated Care Pilots should look at the complete restructuring of the way primary and secondary work together and they would like to see the birth of some kind of geographically-based health maintenance organisation. If you want more on this, it is certainly worth reading their ‘treatise’ from last year In sickness and in health: achieving an integrated NHS (see www.nhsalliance.org). And for lessons from around the world in achieving closer integration of health and social care, including Kaiser Permanente in the US, there is an excellent briefing paper from the University of Birmingham’s Health Service Management Centre. See www.hsmc.bham.ac.uk for Only-connect: policy options for integrating health and social care.

Continuing attempts at organisational solutions to integrated care do remain, such as joint Chief Executives and joint Directors of Public Health posts between PCTs and local councils. The most radical has been in Herefordshire, where essentially at the top, the co-terminous County Council and NHS Authority (PCT) have now merged. How does one account manage such an organisation? Certainly wholesale mergers could remove organisational boundaries and thus help to better integrate community and hospital based specialty teams in clinical areas like dermatology and rheumatology. This has actually already happened within London SHA, where Barking and Dagenham PCT has transferred its community services to North East London NHS Foundation Trust. Do expect these ‘experiments’ to continue and, as usual, the key issues for industry in all of this are the likely implications on future ways of working.

Ten key points

1. Integrated care is not new and there have been a number of experiments in this area over the years. If it is new to you, check out www.venturetc.com for a free ICP email newsletter and note that the DH host an Integrated Care Network site.

2. The ICPs are piloting news ways of working. You might have to do the same, working across both primary and community care, across primary and hospital care, and across commissioners in both health and social care (i.e. PCTs and Local Authorities Social Services Departments).

3. Delivering these new integrated models of care will be challenging. There may be opportunities for you here, where appropriate. Certainly there will be some learning from your Scottish, Welsh and Northern Irish colleagues.

4. The ICPs are also tied into the personal healthcare budgets and more general reform in social care. Do you know about the new White Paper in social care?

5. This initiative, like many others, is creating brand new organisational ‘creatures’. Do you know what a social enterprise organisation is? Do you know what CIC and LLPs are? The point here being that different ‘styles’ of organisational culture are beginning to appear.

6. Some Foundation Trusts seem to be using this agenda to promote vertical integration with primary and community care, saying that the managed care model in the US works well.

7. Proto-type Community Foundation Trusts are also bubbling away in the background, as are new PBC models.

8. Although they are only small scale at the moment, it is hoped that the integrated care pilots will innovate with big new ideas and lead future policy. If this should be the case, please do stay close.

9. Please also note carefully the focus area for each ICP as there may be synergy with your disease area. So in terms of account management you too may need to ‘deep dive’ and keep up to date, especially if one is in your health economy and the clinical area is relevant. Do please keep your NHS eyes and ears open…

10. And again in terms of intelligence gathering for account management, also check out the 20 who didn’t make it through the last stage and the 64 which did not go beyond the first phase. They must have has something about them!…

Alan Jones is an occasional contributor to Pf. He writes, presents and commentates widely on the ongoing reform within the NHS and their implications for pharma. An independent healthcare policy analyst, adviser, trainer and facilitator, he can be contacted at alan.jones28@virgin.net.

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