Integrated services: making the right connections

Partners working collaboratively across Nottingham and Nottinghamshire Sustainability and Transformation Partnership (STP) have made some major strides forward in creating an integrated care system over the last few years. They have implemented new models of care, made some initial forays into using capitated budgets and done more thinking than most about the infrastructure and framework needed to make integrated care a reality.

Prime minister Theresa May highlighted the work in mid-Nottinghamshire in particular as an existing example of the ‘NHS we want to build for tomorrow’ when she announced details of the increased funding for the NHS from 2019 in her speech in the middle of June. But rather than build on successes in a piecemeal, service-by-service way, the STP is now keen to explore how it can learn the lessons from its journey so far and implement a whole system approach to transformation across the whole county.

The STP covers a population of just over one million and has a collective health spend of some £3bn. Its ‘do nothing’ gap across the whole STP was £473m by 2020/21 – with a further £155m if you add in a social care shortfall. As with the rest of the country, more collaboration and system working is seen as the solution to some of this gap – although Nottinghamshire has arguably been at it longer than many other systems.

With six clinical commissioning groups, two acutes and an integrated mental health and community provider – and eight local authorities – the county has been exploring opportunities to collaborate and transform services since the formation of clinical commissioning groups in 2013. Its enthusiasm for transformation is reflected in the fact that it provided five vanguards out of the 50 selected by NHS England to pilot new ways of working following the Five-year forward view.

Recognising its existing work in this area, last year it was unveiled as one of eight new accountable care systems (subsequently rebadged as integrated care systems) that would pioneer a more formal approach to system-wide collaboration.

At the time of the announcement, NHS England said the initial focus would be on Greater Nottingham – one of two distinct delivery units alongside mid-Nottinghamshire.

But Marcus Pratt (pictured), programme director for finance and system efficiencies for the STP, says the clear aim now is to see the whole county as a single integrated care system and to reduce the delineation between the two.

 It is in discussion with NHS England about this. It is also starting to get a bit more clarity about the different roles of the different players within the system.

STPs have been set up as partnerships of commissioners and providers and the future is definitely about much closer working. The ICS – evolving from the STP – will undertake strategic system planning, commissioning and oversight, aligning with the King’s Fund’s view of ICS functions. 

The King’s Fund also talks about integrated care partnerships as alliances of providers collaborating to deliver care that meets the requirements specified by the ICS. In Nottinghamshire, the STP contains two collaborative partnerships, made up of NHS and local government organisations, focused on delivery of the strategic objectives – mid-Nottinghamshire and Greater Nottingham, each built around separate vanguard programmes.

Tactical moves

Nationally there has been some discussion about how the move to integrated care could see commissioning roles split with some ‘tactical’ commissioning functions – particularly around supply chain management and co-ordination – moving within integrated care organisations or provider alliances. 

There is a common goal of delivering the best possible outcomes and best value for money, but Mr Pratt says the STP is ‘currently defining the roles and responsibilities of the ICS and the delivery units that sit within it’.

To an extent, the ICS may be interested in setting outcomes that address the specific needs and priorities of its population. The provider partnerships would decide the best way of delivering those outcomes, integrating to meet these requirements.

Mr Pratt says it is feasible that the provider partnerships could implement services to meet local requirements, although the overall standards and outcome measures will be the same across the whole area. But there will be cases where the ICS will want to be more specific. ‘It might specify a standard pathway across the whole area, so the design will have to sit at the ICS level,’ he says, although in reality he suggests it may need to be done by providers and commissioners working together.

Nationally, there is an expectation that some of the roles currently undertaken by commissioners – particularly those related to more transactional activities– are likely to move inside ICPs or provider alliances, where different contracts and sub-contracts will fix the preferred pathway in place.

This inevitably would leave smaller commissioning organisations, which are then likely to come together – in partnership or more formal arrangements – providing a strategic commissioning function that can look across the whole population and take a longer term view (see box).

CCGs in Nottinghamshire are already working very closely together. There are shared management arrangements across the two CCGs in mid-Nottinghamshire and also across the four Greater Nottingham CCGs, which also have a joint commissioning committee.

Mid-Nottinghamshire’s transformation journey has been under the banner of its Better together programme, which started in 2013 and gained vanguard status in 2015. The programme initially identified four key areas of focus, similar to many areas around the country – urgent and proactive care; planned care; women and children’s care; and community and mental health services.

It has had some good success with a clinical navigation system – a manned, IT-supported service to help clinicians refer patients to the most appropriate service rather than automatically referring to secondary care. It has won plaudits for its single front door to A&E, with a single triage service directing patients into a primary care or full A&E service – seen as an interim measure until other measures deflect the activity that would be better handled in a different setting.

And it has also reduced admissions from care homes by improving the advice and support provided to homes, particularly around prescribing and administering of drugs.

Prism service

Perhaps its most high-profile transformation project has been with the use of risk profiling, multidisciplinary teams and virtual wards to support the top 2% of the population most at risk of hospital admissions. Its Prism service, in operation in the mid-Nottinghamshire area for more than five years, has helped to offset growth in avoidable admissions. Over a five-year period from 2012/13 to 2017/18, mid Nottinghamshire saw an absolute increase of 3% in non-elective admissions compared to an all-England average of 14%.

‘We saw some quick wins initially but then we started noticing a spike in non-elective admissions,’ says Mr Pratt. ‘We realised that as it became business as usual, some people were getting stuck in primary care.’

Rather than being within the Prism service for a finite duration, people were simply staying there, reducing the capacity for new patients, who then entered the system via more traditional routes. However, commissioners and providers worked together to re-specify the service and maximise its efficiency and effectiveness.

Also of note has been a new musculoskeletal service, with a dedicated consultant-supported but physiotherapy-led triage service massively reducing the number of patients being seen in specialist outpatient clinics. Once fully operational some 13,000 patients would be expected to go through the triage service each year. The costs involve an investment in physiotherapists to deliver the triage service and to accommodate the transfer of a small number of patients who would previously have been on a surgical pathway. But there was an expectation of a 25% reduction in outpatient activity and an initial 5% reduction in inpatients (rising to 15% by year 3).

The service has been running for just over a year and Mr Pratt says it delivered its target in financial terms. ‘But it came in a slightly different way to expectations,’ he says. Overall inpatient activity reduced by more than expected, while the outpatient reduction was not as high as hoped.

Overall savings were £2m in 2017/18, which was seen as a good result. However, more is expected of the service in 2018/19, when the system hopes to deliver a further £2.5m on top of the 2017/18 savings.

Logistical approach

In Greater Nottingham, the focus has been more on understanding the logistics of setting up a shared health and care system. This has been supported by international experts Centene and Ribera Salud, which have significant experience of integrated care models across the US and in Spain.

An actuarial analysis, which benchmarked Greater Nottingham activity and cost compared to international ‘well managed’ integrated care systems confirmed a significant value opportunity. This has been the starting point for decisions to be informed by patient/population and system value rather than organisational benefit. 

The emerging design solution to achieve the value opportunity provides a totally new approach. This involves:

• Flow of consistent data
• Application of new analytical capability
• In-built monitoring and oversight
• Continual improvement processes
• Freedom to act and invest where change is required
• Agreed outcomes
• Strengthened accountabilities.

Together, Mr Pratt says this makes the whole model far greater than the sum of its parts. ‘It embeds best practice into the whole system aligning all providers in their ability to achieve their roles and responsibilities within a well-managed system,’ he says.

Early impact and benefit is already being realised. For example, the establishment of a new integrated discharge function has resulted in an increased number of weekly supported discharges from the acute sector (240 compared with 180 per week). And the locally named F12 project has established best practice referral templates built into primary care clinical systems. This is resulting in reduced clinical variation and making everyday tasks easier and more efficient.

Mr Pratt says the Greater Nottingham work, which also includes aligned payment and incentive mechanisms, will inform further work across the system. For example, the Prism model could arguably be rolled out across the whole of Nottinghamshire. However, there is a similar model operated by the Greater Nottingham CCGs and the system is keen to have a consistent approach. ‘Informed by the work from Centene, we’ll look at both models to come up with a best practice standardised approach to delivery,’ he says.

The advice on payments and incentives will also be helpful. The system has done some detailed work on capitated budgets (see Healthcare Finance July 2016 and July 2017). But last October it moved from theory to practice by launching a capitated budget to support the MSK work in mid-Nottinghamshire.

This involved a mechanism to share risks and rewards across commissioners and providers – something that is likely to be needed alongside any future capitated budgets used as part of integrated care systems.

This work involves setting a budget informed by current levels of spend, adjusted for planned and expected activity changes and for stranded costs. There is also a risk share arrangement involving marginal rates and a system risk/reward pool.

It is complex, but attempts to assign risk relative to the amount of influence different organisations have over the drivers of that risk.

While this approach continues to be developed in 2018/19, there has been no rush to expand the approach across other service areas at this point. In part, this is so any future approach can reflect the recommendations emerging from the Centene work. 

Mr Pratt says that the system is also keen to avoid a piecemeal expansion. ‘We want to learn the lessons and implement a whole system model with a single budget across all services, possibly differentiating between emergency and elective care,’ he says.

The priority at the moment, particularly in an environment of such limited finances, is to ensure the system as a whole is as efficient as possible rather than move faster with revised payment systems. There are other ways to move money around the system.

‘As all STP partners are working to reduce costs across the system, the acute-focused payment by results isn’t helpful in some areas but it is not a huge barrier to transformation at this point in our journey,’ he says, although new payment mechanisms will be needed in the medium term.