interviews

The old business models are not viable

NHE spoke to Monitor’s director of integrated care, Catherine Pollard.

The benefits of integrated care to the patient are obvious: a more seamless and joined-up experience, without the fragmentation and confusion and poor outcomes that can arise when several organisations provide distinct episodes of care without reference to that patient’s wider needs. 

But, done well, integrated care could also be a lifeline for smaller NHS providers, says Catherine Pollard, director of integrated care at Monitor, who says new ways of working offer a shot at ‘mutual viability’. 

She explained: “It’s really about thinking about the health and care system as a complicated web of interdependencies. Hospitals are very dependent on out-of-hospital services, particularly when it comes to emergency admissions; health is really dependent on social care; commissioners are massively dependent on providers to actually deliver care as set out in their commissioning intentions. 

“Local leaders are increasingly recognising that to meet the needs of people, they need to work with partners across traditional divides. I’ve been at Monitor for three years, and the conversations I have with chief executives of acute hospitals now, compared to when I got here, have a really different tone. Provider chief executives are really cognisant of the fact that their traditional business model – doing more and more activity to recover fixed costs – is not going to be viable and nor is it necessarily serving patients best. 

“I’m particularly impressed that organisations like Salford Royal, Yeovil, Northumbria, South Devon and Torbay are acute providers who have seen their organisational success and their future as being intertwined with those of other local providers. At the most extreme, they are looking to take on financial and clinical accountability for population management: the glimmers of an ‘accountable care organisation’ within the NHS. 

“‘Mutual viability’ is a recognition that providers across settings are dependent on each other if they are all going to deliver their best for local people.” 

She said that Monitor’s work on both pricing and competition, and on foundation trust regulation, can be used to act as an enabler to integrated care and to knock down barriers. She explained: “We think we can do more to interweave integrated care into our policies in both of those areas. 

“Monitor’s primary duty is protecting and promoting the interests of patients. We think integration is really important, particularly as demographics change – we’ve got more people with long-term conditions and complex needs, and in particular people who need a mixture of health and social care.” 

Pricing and pathways 

It has become a truism to note that it is easier to incentivise activity than incentivise co-ordination or preventative healthcare. Monitor itself admits that pricing models do not always support the delivery of integrated care. 

We asked Pollard how Monitor can ensure pricing is an enabler, not a barrier – and whether some form of capitation is the answer. 

She said: “It’s a good question, and one we’ve been grappling with since I’ve been here.

“There is no such thing as a perfect payment mechanism. They all have desirable behaviours that they inspire, and undesirable ones. Having reflected on the strengths and weaknesses of the existing payment system that we inherited from the Department of Health, we wanted to try to think about that mix of incentives. 

“What would support the care models set out in the Five Year Forward View? There are a range of different payment approaches you could use to deliver more integrated care. A capitation payment, if linked to outcomes, if sensibly calculated with the right sort of risk adjustments, and if set over a long enough period – we think that is quite promising as a payment approach. There’s certainly international precedent for it: it’s used in Spain, and is the approach being used by accountable care organisations in the US.” 

Payment structures are an enabler but “quite a long way from being sufficient” to deliver integrated care, she added. 

“Actually, all of the really hard work is done in the way that healthcare delivery is changed on the ground – the conversations that happen differently between frontline staff and patients, the adoption of technology, working across traditional professional boundaries, having more generalists rather than specialists. The payment system can help, but lots of things around leadership, culture, values, outcomes measurement, data, are also absolutely essential.” 

Behaviours 

Asked to expand on that point, Pollard explained that many supposed barriers to integration are actually figments – they are perceived barriers, rather than actual policy barriers. “Local leadership, and work on values and culture and workforce development, can overcome all of those perceptions around information governance, financial flows and so on. 

“However, there is more that we can do nationally to change the ‘default setting’. Right now, the national policy default is more oriented towards traditional models of care. But the vanguard programme is trying to understand: if you were going to make some of these new care models become more the ‘defaults’ themselves, what would you need to change? There is quite a lot of heroic leadership required at the moment.” 

Pollard used to work in Tower Hamlets, where she said that successful work on diabetes was achieved because “one great diabetes consultant and a couple of really great GP leaders really believed in it and saw it through”. 

The rise of ‘integrated care organisations’ 

There has been much talk in recent years of the evolution of true ‘integrated care organisations’ (ICOs) in the UK, including during the general election campaign. 

Pollard said: “At Tower Hamlets, I was able to see first-hand how a shift in primary care organisations could come about. It took time and a lot of effort, but actually really transformed how diabetes care was delivered, over the couple of years I was there. 

“People like Paul Mears at Yeovil [District Hospital NHS FT], Sir David Dalton at Salford [Royal NHS FT], the Torbay team – they actually do have aspirations to become ‘population management organisations’, which really is what an ICO is. They will look at improving the experience and access to healthcare services across the spectrum, with an emphasis on prevention, proactive management, use of technology, and support for self-management. 

“The voluntary sector has a really big role to play though as well. We shouldn’t be precious about where the ideas come from. 

“I do believe the current NHS architecture and providers, including primary care ones, will be able to deliver. But it will take time and be a really long journey for them.” 

Regulation 

Under the licensing scheme, all holders have to abide by the ‘integrated care condition’, which “prohibits licensees from doing anything that could be reasonably regarded as detrimental to enabling integrated care”.

Pollard said Monitor has had its first potential complaint relating to that condition, but could not say more publicly until and unless the complaint is verified. 

She said that understanding of the new integrated care condition among providers is still “quite limited”, which is why new guidance was published earlier this year. She added: “As we go forward, particularly with the increased work our development team are doing as part of our new provider sustainability directorate, we’ll be looking to bed-in those key messages.” 

Monitor also has a duty to prevent anti-competitive behaviour that is detrimental to patients. The competition team has to ensure commissioning decisions are made in a transparent evidence-based way, and that innovation in care models is enabled. 

Pollard said: “Commissioners are guardians of public money and they need to be seeking best value. It’s really important, as they seek to work out who the most capable provider is, that they do so in an unprejudiced and transparent way. 

“On innovation, good commissioning done in a transparent way – which thinks about patient needs and innovative solutions – can be quite an enabler.

“We definitely don’t see an inherent tension between competition and integrated care. 

“We’re also keen to see how we can make choice policy compatible with the creation of these more integrated, accountable care organisations. They have successfully overcome this in Spain for example, where if a person goes out of the network, their provider (as opposed to the commissioner) pays the [new] provider.” 

Support 

Monitor is doing more to proactively support the sites that are trying to “push the horizons” on this, Pollard told us. This includes the 25 integrated care pioneers, the eight Integrated Personal Commissioning sites, and the 29 ‘new care model’ vanguard sites. 

She said: “Obviously some sites overlap, and we’re keen to ensure the support we offer is done in a seamless and joined-up way. But we’ve got some good examples already of where we’re looking to provide advice, be it on how to design a new payment approach, reviewing businesses cases, or potential organisational transactions.” 

NHE will speak to Pollard again later in the year to hear more about the evaluation and feedback from some of these groundbreaking sites. 

Scale of the challenge 

Pollard went on to tell us: “Certainly, I and my team are quite aware of how daunting a task this probably feels for providers and commissioners out there, particularly in the context of all the pressures financially and the pressures around performance objectives. 

“We’d advocate for people to persist and persevere. This is something that is going to take time. 

“The places that seem to make progress earmark time for ‘transformational conversations’. Torbay has its joined-up care board, where maybe for an afternoon a month, there is talk about the integration agenda, rather than just performance or financial issues. It’s going to require active commitment from local leaders to make that time, but they should keep going and keep coming back to national bodies like Monitor if they think our regulations are getting in the way, or causing such friction that their schemes are never going to get off the ground.” 

The evidence base 

Supporters of integrated care – which includes virtually everyone in the NHS, in principle at least – usually say that it improves the quality of care for patients, and decreases costs by removing fragmentation and duplication, and by preventing more emergency admissions and other expensive episodes of care. 

The evidence base for the former is well-established, but the evidence base for cost savings, particularly in the NHS, is “much more variable”, Pollard said. “There is a need to support a plurality of different approaches to working out what the right care model is. 

“My current hypothesis is that there’s not going to be one care model that works everywhere. Different parts of the country will need different integrated care models, based on where local leadership comes from, but also issues of geography and so on. One size definitely doesn’t fit all.”

Tell us what you think – have your say below or email [email protected]