Commissioners, whether at NHS England, Clinical Commissioning Group (CCG), or local authority level, are increasingly looking to integrate care across hospital and community as well as health and social care.
It’s the only way for the system to gain enough efficiencies to be able to deal with the massive growth in demand from an aging population increasingly living with long term co-morbidities. This has resulted in the fundamental shift from giving contracts to the local incumbent NHS provider of a specific (‘silo-ed’) service to any lead provider (NHS or private) providing care to an entire population.
This has a number of implications. First, is the idea that private organisations can compete on a level playing field to NHS incumbents. Section 75 rulings, which require CCGs to tender out all services to all providers rather than automatically giving them to the local NHS provider, is a fundamental driver of this. Even heavily pro-NHS CCGs are now being forced to consider if private providers can offer a better deal for the population they are responsible to look after.
Second, payments for care are shifting from activity based, per-procedure for example, to capitated population base (fixed amount of money for looking after all care needs of over 65 year olds, for example). This puts the onus onto the provider and changes the incentives, not to just deliver an increased number of procedures, but to better maintain the health of the population so that they don’t need to do so many procedures, completely changing the way providers view the world and their purpose.
Third, it is impractical for one provider to deliver all care under an integrated care contract and increasingly providers are either partnering (including partnerships between NHS and private providers) or subcontracting some services. The concept of prime contractor has surfaced whereby a main provider contracts with the CCG and then subcontracts other providers (some of whom may have unsuccessfully bid one the same contract tender) to deliver the care.
Alliance contracting, common in the construction industry for complex projects, has become popular now in healthcare. Under alliance contracting, the prime contractor creates a special contract with the subcontractors where payment is not based on individual subcontractor performance, but on the performance the service overall - linking every member’s success in the contract to one another. This creates incentives for subcontractors to help out each other and ‘pull in the same direction’ as they are ‘in the same boat’. It also reduces the complexity of contracts between the providers and litigation.
As a result of this doctors and multidisciplinary teams will have to work with care coordinators, perhaps employed by lead providers, perhaps from the private sector, to look after patients. This shift from a purely clinical, doctor-led approach to care to a more managed full patient pathway approach should start linking up clinical pathways, rather than encouraging the status quo of ‘silo-ed’ service delivery, and integrating care using fact backed evidence.
Data will also become more important. Currently, patient clinical data is only available to the organisation that delivers the care direct to the patient. For example, the CCG does not have visibility over how money has been spent by acute providers and even less visibility over how block community and mental health provision has been allocated.
They also do not have access to clinical data held by providers, making it impossible to review outcomes, identify patients getting dis-coordinated care, and create an integrated care strategy on a whole system basis. This has to change. If commissioners, lead providers, and subcontractors are to deliver integrated care, to improve patient care, patient experience, and reduce cost inefficiencies, they must be able to analyse and leverage big data sets from all stakeholders.
Current legislation prevents this from happening and much work is needed to clear the road to data sharing in this brave new world.
Dr Leonid Shapiro is managing partner and Dr Michelle Tempest, a partner, at Candesic, a strategic consultancy serving the NHS, private operators, and investors.