Integrated care – the new contract is a good start, but more is needed

After much delay, and having defeated legal challenge from opponents, NHS England has now published its proposed Integrated Care Provider contracts for consultation.

These contracts, when introduced, will overcome the divisions between different NHS funding sources and contract types that have for so long acted as a barrier to the integration of NHS care.

In the absence of a clear contractual mechanism for integrated care, local systems with ambitions to integrate have developed instead a proliferation of non-legal, collaborative agreements between local care providers and their commissioners.

These sorts of arrangements, needing the alignment of multiple stakeholders, are invariably difficult to establish and take time to mature.

Difficult decisions

But even when these arrangements are agreed, they also may not always prove sufficiently robust to take the difficult decisions that are often needed when radical changes to care delivery are planned.

With the new 10 year plan imminent, and surely containing further exhortation to create integrated care systems, the new ICP contract should be seen as a fillip for those looking to develop new approaches for better population health and care.

It should address the long term funding uncertainty and the misaligned financial incentives that were cited as problematic by vanguards

But while welcome, the new contract should not be seen as a silver bullet. The recent National Audit Office report into the new care model vanguard programme gives pause for thought.

Even though the vanguards were the centrepiece of the Five Year Forward View, and the shock troops of the integrated care movement, they have struggled to make the impact that many hoped and expected of them.

To be sure, the NAO found many positive outcomes of the programme (for example, the vanguards appear to be relatively successful in reducing the growth in emergency admissions and thereby delivering some financial benefits).

But overall, the NAO concluded that their long term impact and sustainability is “still not proven” – notwithstanding central funding of £389m to support them.

Unfulfilled objectives

A key original aim of the vanguard programme was that it should create care models that can be replicated quickly across the NHS. This has not yet happened.

To date, the programme has introduced new care models to 9 per cent of the country’s population (with a further 15 per cent being served by a “primary care home”, a model with characteristics similar to those of multispecialty community providers).

This is some distance from the commitment in the NHS Mandate to have at least half the population covered by new care models by 2020-21.

No vanguard had achieved full implementation. The new contract is likely to address at least some of the barriers to progress identified by the NAO

Moreover, the NAO suggests that the depth of transformation, as well as the scale, has been lacking. By the end of last year, pilots had progressed on average only one third of the way to full implementation (in terms of delivering the key features of the new care models).

No vanguard had achieved full implementation. And if the well supported vanguards have struggled to overthrow the traditional ways of delivering care, what hope for the rest?

The new contract is likely to address at least some of the barriers to progress identified by the NAO. In particular, it should address the long term funding uncertainty and the misaligned financial incentives that were cited as problematic by vanguards (and everybody else that has attempted integration!).

But at least three other things are going to be needed if integrated care providers (and their close relatives the “integrated care systems”) are to succeed.

Essentials for success

First, transformation funding will be essential – not just to implement community based care before expecting activity to shift from hospitals but also to support organisational and leadership development, training and technology.

The first wave of vanguards were financially supported but the designated funding for the next five waves was redirected to support the overspending acute sector. A better symbol of the seemingly irresistible gravitational pull exerted by hospitals over NHS money could not be imagined.

Second, the regulatory system needs to be joined up to support place based care. Here, there is some hope.

The ongoing alignment of NHS England and NHS Improvement makes it more likely that a single view of the right health and care configuration and outcomes for a population can be developed… and, with local vision and some regulatory “persuasion”, might actually be achieved.

The artificial trading of deficits across the “purchaser provider” divide is increasingly unhelpful. What is needed is a clear and unambiguous view of the resources that are available to support the population and how they can be used to best effect.

Third, and perhaps most important, the health and care system needs to recommit itself to wholesale transformation and not just to “pilots”. Paradoxically, the new risk to achieving the long awaited transformation of care may lie in the recent financial settlement.

It is significant enough to stave off financial meltdown, but not so generous that the NHS can continue unchanged. The new money must be used to unlock the necessary changes.

Transformation tends to get the best purchase when there is the motivation of a burning platform. So, the NHS needs to quickly understand that a modicum of financial relief is not a prescription for “business as usual”.