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From Hospitals to Health Systems: The role of Trusts in capturing the integrated care opportunity in England

An independent report by Ben Richardson January 2016

Copyright © 2016 Carnall Farrar. All rights reserved

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1 Executive Summary

England’s NHS faces the prospect of an ageing population, an increasing burden

of chronic disease and flat cash. Against this backdrop there is are clear

opportunities to deliver better care and a better patient experience at a lower

cost. This paper aims to explore what the opportunities and challenges are with

delivering genuinely integrated care, both by examining the literature and

evaluating concrete examples from the UK and internationally.

Evidence suggests that in the order of a 20% reduction in emergency admissions

can be achieved; making the Better Care Fund goal of a 3.7% reduction in

emergency admissions is just the start. However, change of this scale cannot

happen quickly –rather it takes more like 5 to 10 years to achieve.

There are broadly speaking two different models for pursuing this opportunity: a

community based model which seeks to build up the capability of primary and

community care to avoid hospital activity in the first place, or alternatively a fully

integrated system where hospitals combine with other providers to deliver an end

to end response (referred to as the multispeciality community provider and

primary and acute care system respectively in the Five Year Forward View).

This paper examines the role of hospitals and their attempts to pursue a fully

integrated model of care delivery. We consider the progress of UK Trusts and

then at two success stories from abroad: Montefiore in the Bronx, New York and

Ribera Salud in Valencia, Spain. In focusing on hospitals, we should not fail to

acknowledge that to exploit truly the value of integration for health gain we need

to consider social care and the relationship between mental and physical health.

The experience of UK trusts suggests that while progress has been made in

agreeing common purpose and establishing governance arrangements, impact

on the ground has been more limited. Key reasons for this are:

1. Payment models are mostly not in place to drive change at scale

2. Information flow has also not been changed to be ‘fit for purpose’

3. The relationship between acute and primary care continues to present barriers.

Given that there are no full UK examples of this sort of model we need to look

abroad to see them. Two in particular stand out as examples: Ribera Salud in


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Valencia, Spain and Montefiore in the Bronx, New York. Both are publically

funded hospitals meeting the needs of the local population, that have brought

together primary care and hospital care and as a result dramatically improved

care. These provide examples of what can be achieved.

Montefiore is a publically funded hospital in the Bronx, New York which, over the

last two decades, has evolved from an organisation on the brink of bankruptcy to

the most successful Accountable Care Organisation in America. In doing so it has

focused on population health, employed 350 primary care providers and created

structures to facilitate affiliation of other primary care providers with the hospital,

all of which has been enabled by a central government driven capitation model

and the development of sophisticated information tools. As a result, it has

delivered a 7% reduction versus benchmark cost trend over 2013-14.

Ribera Salud is a publicly funded hospital system in Valencia, Spain. Backed by

long term capitation contracts it has put in place a system that, since the

integration of primary and acute care, has delivered 20% reduction in emergency

activity at 25% lower cost than peers. It has similarly focused on population

health, facilitated by aligning the incentives of primary and acute care clinicians

and enabled by the flow of information.

Reflecting on the experience of Monterfiore and Ribera Salud suggests some key

themes for the core role of hospital organisations in delivering integrated care

including: organising and orchestrating the system, standardising the pathways

across the entire catchment, operationally managing the risk of escalation,

investing at scale in estates and information, leading research in improving health

and clinical practice and providing education to current and future practitioners.

The leading teaching hospitals have the depth in leadership and the scale of

operation, which makes them the ideal place to start this transformation.

Comparing the current position of the situation in England with fully formed

international examples suggests some clear priorities:

1. Primary care is pivotal and it must be made easier to include it

2. Payment innovation is a crucial lever and one that should be pulled centrally

3. Information flow must be encouraged particularly through clarifying

information governance and making investment in information

4. Backing innovation at scale with investment in transition to new models


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2 Introduction

England’s NHS faces the prospect of an ageing population, an increasing burden

of chronic disease and flat cash. Against this backdrop there is a clear opportunity

to deliver better care and a better patient experience at a lower cost. This is often

described as supporting people to live healthier lives, delivering care close to

home, reducing reliance on hospital care and ensuring a seamless individual

experience. Integrated care is a term that is often used loosely. This paper aims

to explore what the opportunities and challenges are with delivering genuinely

integrated care both by examining the literature and evaluating concrete

examples from the UK and internationally.


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3 From hospitals to health systems: the strategic case

Much has been made already of the great benefits in better care for patients,

which would make integrated care a good thing to do if it were affordable. In

fact, the evidence shows that a 20% reduction in emergency admissions and an

even greater reduction in bed days, relative to the current trajectory, is possible.

There are many examples of impact of this level from overseas. One example is

Chen Med, a primary care based provider in America, which delivers 38% lower

bed days per 1000 population than peer performance for the publicly funded

Medicare programme. (Health'Aff'June 13, v32, no 6, 1078 to 1082). Another well

known example is Ribera Salud, which has delivered care at costs about 25%

lower than peers (Ribera Salud). A review of 34 systematic reviews with sufficient

data to analyse results showed on average a 19% decrease in emergency

admissions relative to peers.

In the UK, the best evidence of what is achievable comes from Torbay. Although

well known as an example of integration, hard data on spend has not been

analysed before. The analysis below shows clearly that Torbay managed to halve

the national growth rate in spend in acute, community and social care, truly

‘bending the curve’.

Exhibit 1. Torbay expenditure

2,930

2010/11

3,470

1,174*(34%)

1,655*(48%)

641 (18%)

2007/8

950 (32%)

1,449*(49%)

531 (18%)

195

2007/8 2010/11

217

116 (53%)

53 (24%)

48 (22%)

100 (51%)

49 (25%)

46 (24%)

Community**health*services*

Social*care*

Acute*services1*

12%$ 18%$

CAGR*%*

3.8*

1.4*

2.7*

5.4*

5.8*

6.5*

4.5*

5.8*

CAGR*%*

Torbay$$expenditure$£m*

SWP$(ex8Torbay)$expenditure$£m*

1 General & acute spend and A&E (excludes maternity and mental health) SOURCE:; NASCIS 2010/1; FIMS 2010/11; L&B 2010/11

6,277 (12%)

15,275*(29%)

31,890 (60%)

53,442

2007/8

8,409 (13%)

17,040*(26%)

41,137*(62%)

66,586

2010/11

7.6*

10.2*

3.7*

8.9*

CAGR*%*

Na;onal$expenditure$£m*

25%$


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Results like this cannot be achieved with the flip of a switch as they require

changes in how the whole system of care functions, including changes across

organisational boundaries. Indeed, one thing that stands out in looking at

successful models is that they are entire systems with combination of payers and

providers that work together differently.

Whilst the opportunity for integrated care systems comes from avoiding

unnecessary hospital activity, there are different ways to achieve this. One model

is to seek to bring together providers in the community outside the hospital to

limit the need for the hospital at all, and another version is to seek to integrate

fully care delivery across community and acute providers. In the Five Year

Forward View these models are alluded to as the Multispecialty Community

Provider (MCP) and the Primary and Acute Care System (PACs).

The first version is a community based system, the aim of which is to bring

together primary care practices with other providers and provide a more intense

model of care (including diagnostics and access to specialist opinion), to prevent

the need for the hospital in the first place. One of the best of these models is

ChenMed, a primary care based organisation that delivers an intensive model of

care in the community setting, focused exclusively on older people and those

with chronic conditions. For instance, instead of a typical list size of 1850 it uses

a list size of about 450 patients per primary care physician. The intensity of care

in this model is funded from a fully capitated payment system and resourced by

savings made in the reductions in acute care. There are many other examples of

systems that organise around the patient in a community setting including, e.g.

Care More (California), Community Care of North Carolina (North Carolina and

elsewhere), the Camden Coalition (in New Jersey). Other versions of this model

have been pursued in New Zealand, Denmark, and parts of Canada (e.g.

Quebec). This sort of model is referenced in the Five Year Forward View as the

Multispecialty Community Provider (‘Five Year Forward View', p.19).

For this model, the economics are relatively clear: if primary care represents

about 10% of total system spend (or say 20 to 30% including community care as

well) a significant increase in resources combined with incentives to reduce

unnecessary hospital activity (which typically accounts for 50 to 60% of cost) is

relatively easy to justify. A 30% increase in primary care would cost 3% of the

total system cost and delivering 20 to 30% reduction in non-elective inpatient

spend (typically 40 to 50% of hospital spend) would deliver 5 to 9% savings in

total system cost.


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The alternative to this approach is to seek to integrate primary care and acute

care along with other providers in a fully integrated system. These rely on the

idea of being able to manage risk in patients through the integration of care

between specialists and generalists, providing additional support in the

community, and moving care to a more planned basis. A striking feature is all

these consider themselves health systems not hospitals. Examples of this sort of

system include famously in the US Kaiser Permanente and the Veterans, but

many in the US are pursuing the Accountable Care model and bringing entire

health systems together with hospitals. In Europe this has been pursued in places

like Jönköping (Sweden) and in Valencia and Basque Region (Spain). This model

is referred to in the Five Year Forward View as the Primary and Acute Care

System (‘Five Year Forward View’, p.20).

Most leaders of hospitals are inclined to believe that they have an important role

in creating a more effective system of healthcare for the population. Emergency

departments are heaving, in part with patients that don’t need to be there. Deep

cuts in social care are making it harder to ensure every patient who needs it has a

package of care in place to enable them to be discharged. At present, thanks to

the marginal tariff, hospitals lose money on every emergency admission. In

addition, reducing length of stay directly benefits hospitals. These two factors

will result in excess capacity that can be either exited or used for other services.

Systems with these features do not emerge fully formed. They develop over a

period of time that typically takes 5 to 10 years before they operate at full

capability. In looking at how multiple individual providers and organisations

come together as systems working within a defined geographic area, there are

several common building blocks that need to be in place:

1. A qualitative and quantitative understanding and focus on specific patient segments;

2. Changes in delivery model to empower patients and coordinate care and embrace multidisciplinary team working;

3. Five key enablers of change must be in place (information, payment, governance, professional leadership, managerial support)

This paper focusses on the role of hospital leadership in delivering integrated

care. There are however very significant opportunities and benefits from the

integration of health and social care and mental and physical health. In particular

the role of Local Government in tackling the increasing public health challenge is


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critical. This paper therefore only addresses some limited aspects of the whole

topic.

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4. UK experience

In the UK there has been an enthusiastic response to the idea of integrated care,

although progress towards it on the ground has been more limited in general.

The role of hospitals in driving towards this is more limited still. A number of

places have made real strides towards it including, in addition to Torbay, places

like Tower Hamlets, Greenwich and Cornwall. These have all shared a major focus

on organising primary and/or community care more effectively around the

patient. There has been an important role for hospitals in facilitating discharge

planning and receiving access to specialist opinion in some cases, but not more

than that.

We consider the experience of UK Trusts. Common themes include:

1. Alignment around common purpose of delivering integrated care to deliver

better care and better experience as well as lower cost

2. Establishment of governance arrangements designed to facilitate

commissioners on the one hand and/or providers on the other to make decisions

to support this goal.

3.Instances of change in how care is delivered on the ground where a clear vision

and governance have combined with flow of funds. All trusts with community

health services have reorganised these in locality zones with extended hours and

easier access.

4.Progress on data: some places have created patient level datasets that enable

understanding of the segmentation of the population and its needs and then use

that information to gear how care is delivered and paid for.

5. A common desire to do more with a frustration in the difficulty of doing so.

Each trust seeks to embrace a fuller agenda of change. Each also has felt blocked

in the ability to do so.

However, in none of the cases looked at have these changes made a material

impact on the ‘core business’ of the acute. There are several reasons for this:

• Aligning very different cultures of the small entrepreneurial business with

large corporate and medical hierarchy of trusts. Alongside this is a risk

that hospitals may see a requirement for standardisation and clear

governance which GPs may see as cumbersome and stifling. Many GPs

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chose their career because of wanting less hierarchy, more flexibility,

more informality and more autonomy

• Varying degree of mistrust makes it difficult to collaborate. Primary care

may perceive an attempt to take over where trusts see a natural

consolidation of functions. To an extent GPs and consultants alike may

find fault in what each is doing

• Payment models are mostly not in place to drive change at scale. The

marginal rate on emergency admissions has created an incentive to avoid

emergency admissions but none of the tools to do anything about it. A

‘permissive’ approach by Monitor to payment innovation has not resulted

in significant changes

• Information flow has also not been resolved. Information governance

concerns have bedevilled efforts to pursue integration (as indeed they

have in other countries). The actions of the centre have not helpful to

make this easier in the UK. Many local areas continue to focus the debate

between a specific application to implement

• The relationship between acute and primary care remains difficult. The

registered list held by the GP is one of the greatest strengths of the NHS.

But divide between GPs and hospitals is significant, reflecting in culture

(small entrepreneurial vs huge organisation), practice and also underlying

attitudes. The national contract and collective bargaining approach make

change difficult. The core economic case for integrated care is to reduce

emergency admissions. The ability to invest in primary care is thwarted by

separation of primary care and acute commissioning. Co-commissioning

creates the potential for CCGs to reunite primary care and acute

commissioning, chairs of CCGs are elected and face LMCs that often

campaign to not make any significant change to commissioning.

Together these factors amount to a lack of guidance to a system that is still used

to command and control. Given these are three critical enablers of the change

sought, it is not surprising that change has been limited.

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5.Learning from international examples

Given there are no full blown UK examples of this sort of model we need to look

abroad to see them. In looking abroad, there are many different types of

approaches to integrated care but when focusing on an example of hospital

systems that have achieved benefits of integrated care, two in particular stand out

as examples: Ribera Salud in Valencia, Spain and Montefiore in the Bronx, New

York. Both of these are hospitals funded with public funds, meeting the needs of

the local population, who have brought together primary care and hospital care

and as a result dramatically improved care. These provide examples of what can

be achieved.

5.1 Montefiore The Montefiore Medical Centre is located in the Bronx, New York. Founded in

1884 it has a long history of looking after the poor and people with multiple long

term conditions. The majority of all its patients are paid for by public funds and

come from the ethnically diverse and economically deprived local area of the

Bronx.

In the 1980s, Montefiore faced a large and imminent financial crisis. It pursued a

set of changes to transform how it cares for people and in the course of doing so

has become one of the biggest and best rated hospital systems and the top rated

Accountable Care Organisation in America. So while many in England would not

aspire to a healthcare system that looks like America, examining what Montefiore

has achieved within this system is important.

The Montefiore Health System includes 4 hospitals, 21 community based primary

care clinics and 17 school based clinics that provide medical, mental health and

dental services. It provides health services to residents of the Bronx through three

entities: a hospital, a primary care group and a fully capitated population. These

three elements overlap to an extent but each is distinct:

• Montefiore Medical Center is a university hospital. Its emergency department at Montefiore Medical Center is among the five busiest in the United States with 297,000 visits in 2014. The hospital provides more than 85,000 inpatient stays per year, including more than 7,000 births

• The Montefiore Medical Group includes 350 primary care providers (PCPs) and operates from 20 primary care clinics with an average of 17 PCPs per site

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• The Montefiore Care Management Company and Independent Provider

Association provide full risk capitated care for 155,000 people, contracting

with government payers Medicare (federal government payor for over 65s)

and Medicaid (state government payor for poor and disabled).

Patients with chronic or complex conditions receive a wide range of services that

promote care coordination including individualised care plans for those with

chronic/complex conditions, intense case management for the most complex and

costly patients, home care through health and care agency staff, telemonitoring

and psychosocial support.

A crucial feature of this model is that Montefiore moved ‘up stream’ into primary

care from its starting point in acute care. This included directly employing primary

care and specialist physicians who were attracted to Montefiore because of its

academic excellence and community mission. Many doctors, however, remain

either self-employed or part of their own medical group and do not wish to

become employed. For these doctors Montefiore created an Integrated Provider

Association (IPA) to engage and align physicians from hospitals, specialists and

primary care around assumption of financial risk and care delivery. It requires

adoption of a set of standards for clinical care and information flow and uses a

balanced scorecard to align incentives. It has built trust by giving physicians a

voice in decisions. The Care Management Company was established to manage

risks for the IPA, providing care management, customer service and provider

relations support. These are capabilities that all primary care providers require

and would make no sense to do in each practice hence the logic of a central

service provider owned by the hospital providing it across many practices.

Montefiore’s Pioneer ACO covers 24,000 Medicare beneficiaries. While there is

no such thing as a ‘registered list’ in America, the ACO ‘attributes’ patients to the

ACO on the basis of using one or more of Montefiore’s 2,400 employed and

community based physicians (Montefiore, Sept 2014). The ACO has an

independent board with participation from the hospital and from physicians. It is

supported by the IPA and Care Management Company, which provide

information tools and care management support, and align incentives for

physicians. The ACO reinvests 60% of savings and pays the balance to primary

care providers (35%), specialists (6%) and the hospital (59%)

(www.montefiore.org/aco).

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The ACO is only possible because of the Pioneer Accountable Care Organisation

run by the federal payer, the ‘Center for Medicare & Medicaid Services’. The

Medicare payment programme is bringing physicians together by moving away

from ‘fee for service’ towards 70:30 upside/downside, risk/reward sharing. CMS

defined and created a limited number of alternative payment models, each with

strict criteria requirements in order to permit providers to move away from fee for

service models. These are outlined below but essentially they offered a 3 to 5 year

commitment to models that shared 50, 60 or 70% of risk. The Pioneer ACO model

offers 70% upside/downside risk, phased in over time.

Exhibit 2 Payment Innovation.

Source: Centre for Medicaid and Medicare Services 2012

None of this would be possible without the flow of information. Montefiore has

developed its health information technology and an enhanced electronic health

record, investing close to $200m across its delivery network. It has created an

integrated patient level data set that supports shared clinical records, risk

stratification, performance reports and a patient portal as well as payment.

The results of Montefiore have been impressive. It has saved Medicare total of $23

million and will receive ~$14 million back in gain sharing. These savings represent a

7% reduction in costs against benchmark levels.

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5.2 Ribera Salud, Valencia In Valencia there has emerged over the last 15 years a system of integrated delivery

of healthcare across primary care and acute care. It is a publically funded system

delivered by a private provider, using a capitated payment model that covers

prevention, primary care, acute care, outpatient, specialist, diagnostic and post

acute care including in home follow up; it excludes pharmaceuticals, ambulance and

dental care.

Ribera Salud is the company that has operated services in Valencia and developed

the ‘Alzira model’. In 1999, the initial scope of services was just for hospital services

for the 235,000 population of Alzira. This was expanded in 2003 to bring primary

care within the scope of what was provided in Alzira. It was also decided in 2003 to

decide to expand into Torrevieja (110,000) with the integrated model although

service delivery did not commence until 2006. Similar decisions were made in 2006

to expand into Manises and Crevillante (140,000 each) and Denia (160,000) in 2008,

with these coming online in 2008/9. As a result of this 5 of 21 health regions are

operated under contract by Ribera Salud.

In an interview, Alberto de Rosa Torner, the Chief Executive of Ribera Salud,

highlighted three key aspects of the Valencia model: the clinical model, the human

resources model and the information model.

The integration of care is driven by a clinical model that includes:

• Population Health Management including understanding and seeking to

address chronic conditions proactively

• Medical link role: A consultant is assigned to each health center, working

with the same patients as the GP, whose role is to implement clinical

guidelines with the local GPs, resolve medical problems in the health

centers and reduce the number of inappropriate hospital referrals

• Expanded roles for nurses: new roles, competences and responsibility:

emergency triage case history management, etc.

• Integrated primary care centres: expansion of some health centres to include

on site x-ray services, accident and emergency departments and medical

specialist outpatient clinics, to bring medical services closer to patients.

• Integrated medical care pathways: To streamline the management of health

problems from primary prevention to palliative care, including acute care,

rehabilitation and chronic care

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• Decreasing variability in clinical practice: the approach to this includes

standardisation of core processes and clinical pathways, combined with

granular performance reporting

• Integrated information systems: Implementation of a fully integrated

computerised medical history system, including nursing and medical notes,

tests and imaging, and allowing interaction between medical and

administrative areas; these systems also provide clinical decision support

The employment and incentivisation of doctors and GPs plays an important role in

aligning staff. Clinicians are salaried employees within a clinical directorate,

organised by clinical coordinators who manage outpatient and inpatient activities

and represent the interests of doctors on the board. 10 to 20 percent of pay is

based on incentives set for each team and linked to specified and quantified goals.

Ribera Salud has a remarkable information system. Each patient has a unique

identifier on a patient swipe card. The card is used at any visit to any facility. Primary

care doctors and hospital doctors can access all information about the patient when

they swipe the card. This allows management of the patient’s progression through

the contact with hospital including managing how long a patient waits as well as

ensuring that every health professional has access to the patient record. The

electronic record is used to measure clinical usage and manage risk, highlighting

key patients that need additional focus. It also enables the accurate coding and

capture of billing information.

Exhibit 3. Ribera Salud Technology to support patients

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Ribera Salud depends on a full capitation payment model. In establishing the model

a 10 to 20 year contract was established for covering the full cost of services within

scope (excluding ambulance and pharmacy), which adds up to about 580M Euros,

reflecting 70 to 75% of the total cost of provision. The money follows the patient,

meaning that patients can turn up to any facility and Ribera Salud must cover 100%

of fees for any patient within their capitation who attends elsewhere

The results of this model have been impressive, particularly since 2003 when

primary care was integrated with acute care. It has contributed to a 20% drop in

emergency activity. During the same time, the total costs of the system have

continued to operate at 25% below average for the rest of the public system. Core

operational indicators are in line with this, showing 38% lower length of stay and

76% more procedures per operating theatre per day.

Exhibit 4 Emergency activity over time

source: Alberto Roser Torner, Integrated Care Alzira, Model, King’s Fund May 2012.

5.3 Insight from international experience At the highest level, both Montefiore and Ribera Salud demonstrate the potential to

‘bend the trend’ and deliver better care at lower cost, driven by reducing avoidable

hospital activity. Their experience of Monterfiore and Ribera Salud suggests some

key themes for the core role of hospital organisations in delivering integrated care:

• Organising and orchestrating the system

• Standardising pathways across the entire catchment

• Operationally managing risk of escalation

• Investing at scale in estates, information etc.

• Leading research in improving health and clinical practice

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• Providing education both to future practitioners and current ones.

Both Montefiore and Ribera Salud share three critical enablers:

• Primary care integration with acute care, although with different

approaches. Ribera Salud uses employed primary care doctors. Montefiore

uses employment and also affiliation, critically with an IPA to support

affiliated doctors. Some common features include: clinical guidelines,

information tools, shared performance scorecard and aligned incentives

• Capitated payment models with 5 to 10 year horizons. These payment

models were defined centrally by government payors and offered to

providers

• Information at scale with the flow of data across all settings of care

supporting care delivery, risk stratification, performance, and patient portals.

6. Reflections on priorities for the UK

The UK starts from a position of some great strengths including universal coverage,

a tax funded and cash limited system, emerging coalitions in almost every health

system to deliver better care and a data environment that includes universal

application of a common identifier. In comparison, however, to what the fully

formed model looks like, there is a large distance to travel.

It is clear from international models that there are multiple ways to achieve

integrated care systems. Each local area will chose its own path based on local

context, relationships and capabilities. Hospitals are not the only answer but where

relationships are good and capabilities are strong, they can play a critical role in

capturing the opportunity in integrated care. For this to happen, however, changes

are needed in four critical areas: primary care integration, capitation and information

and investment in innovation at scale

6.1 Primary care It is obvious from the international examples that primary care providers have an

essential role to play in any model of care designed to improve the management of

population health. It is also obvious there is no single model of how to do this.

Hospital trusts and partners in primary care that wish to explore the development of

integrated care systems need to explore and develop multiple models including:

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• Employment of primary care physicians by trusts

• Join ventures between practices and trusts

• Affiliation with aligned clinical practice, incentives and information

For it to be attractive to primary care to consider one of these options, hospital

trusts need to be able to offer something of value. The experience of Montefiore

and Ribera Salud suggests this may include enabling payment, clinical standards,

information, access to staff, facilities and training.

Several things are required to support this:

• Coordinating care in multidisciplinary teams

• Greater resources need to be channelled at avoiding admissions and

speedy discharge with care coordination and home support

• These resources can only be made available along with tightly aligned

incentives such as a shared balanced scorecard reflecting quality,

experience and cost

• Co-commissioning to drive delivery of a new model of care and ensure that

it captures the benefit of using the acute budget to invest in savings

• Support should be provided for transformation of care but linked to

achievement of levels of performance.

6.2 Payment The lesson to be learnt from payment innovation abroad is that form follows

function. It is important to design payment models to achieve specific goals. The

goals that are relevant in the UK are:

1. reduce emergency admissions

2. reduce length of stay

3. increase care in the community to proactively manage population health

4. provide resources to transform care delivery

5. align incentives of primary and acute care providers (at minimum, ideally also others) with the above.

To enable the flexibility of primary/community care organisations to develop as they

desire as well as enabling hospital trusts to develop into fully integrated systems

requires a two track approach to payment models:

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• a capitation model needs to be developed to drive emergence of

accountable care organisations based on funding the entire health and care

costs for defined segments of the population

• a primary care based model that instead of capitating the entire care costs,

provides for an enhanced level of care to support care coordination for

patients with chronic/complex conditions.

This should include:

1. providing 5 to 10 year contracts

2. phase in over time

3. having clear requirements for a small but critical number of clinical standards

(e.g. care coordination, access)

4. requiring some specific organisational capabilities (e.g. multidisciplinary

team working)

5. a balanced scorecard for delivery should be introduced which includes

reducing emergency activity and performance against benchmark cost trend

as well as improving quality and patient experience through a balanced

scorecard.

These models should be developed centrally and a limited number (e.g. 2 or 3

variants) made available which providers could opt into. Although there is a

common desire to allow bottom up innovation throughout the NHS, international

experience suggests that payment model design is complex and requires scarce

skills to develop robust models. Given the economic case for integration depends

on reducing emergency admissions and facilitating discharges, it must consider the

impact on hospitals.

Given a typical A&E catchment of 500,000 or an emergency centre with a

catchment of a million there are somewhere between 50 and 100 potential fully

integrated systems within England. At present these relate to 211 clinical

commissioning groups with an average size of 226,000 implying that between 2.5

and 5 CCGs are required to come together to align to a payment model for a single

system. This creates either risk of multiple conflicting payment models or

alternatively requires CCGs to bind together. A permissive approach to payment

innovation is going to take a long time to achieve anything. If we wish to see

something faster, a central drive will be required.

6.3 Information

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None of these changes are possible without the flow of information. England has

unique assets in the NHS number and the commitment to universal electronic

records in primary care and acute care. To realise the potential we need to catalyse

the flow of information and with it integration and innovation through several steps:

• The adoption of the NHS identifier will be mandated for all providers of

health and social care from next year

• The centre needs to invest in developing a locally adoptable solutions for

information governance this year and then mandate the required solution

be adopted by next year. This will in all likelihood mean that every provider

will have to sign a legal agreement for information sharing. The focus

should be on driving to full coverage locally

• An information utility needs to be established for each integrated care

system, which creates matched patient level datasets and the flow of

information across settings. It should not be assumed that a single national

utility is the best solution given the poor track record of the health and

social care information centre. It simply needs a trusted local host. Indeed,

the only places in the UK with matched patient level datasets have done so

despite, rather than facilitated by, the HSCIC

• The requirements of the information utility should be defined as enabling

key functions including:

1) Real time access to medical records across all settings of care

2) Risk stratification/segmentation and care planning

3) Performance measurement

4) Payment

5) Patient portal

• Investment in information should be facilitated through provision of a 3:1

match of national non-recurrent funds for investment in new information

tools subject to a business case.

6.4 Invest in innovation at scale Delivering measurable change will require innovation at scale sufficient to enable

new models of care delivery, new payment models and the unleashing of flow of

information. This will require the double running of services, investment and the

funding of recurrent vs. non-recurrent costs to achieve transformation

Assuming a 20 to 30% reduction in emergency activity, 10 to 20% reduction in

length of stay and promotion and development of healthier individuals, this is likely

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to deliver 5 to 10% gross savings. With about 2 to 3% investment in primary and

community care (reflecting a 10 to 30% increase in spend) to achieve this, recurrent

net savings of 3 to 7% could be achieved or roughly £3 to £7 billion overall.

Assuming a ramp up of 5 to 10 year, a one time investment of the same amount

would be an excellent investment by any measure. Such investment should not be

seen as a handout, but made subject to a rigorous process of bidding for resources.

This is at least an order of magnitude greater scale than current efforts

6.5 Conclusion There is an opportunity to deliver better care more cost effectively by working in

integrated care systems. There are multiple ways that these systems could work,

including whether hospitals function as a core part of the solution. Hospitals have a

lot that they could offer, but equally it is not just up to them. The willingness and

desire of partners in primary and community care to work together with acute trusts

is critical and will depend on trusts being able to offer something of value and a way

of working together that feels attractive (which may be alignment as opposed to

employment). For these things to happen payment models must change and the

flow of information needs to be liberated and the centre needs to back innovation

at scale.

from hospitals to health systems: the role of trusts in ...€¦ · from hospitals to health...

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