Monitor is the sector regulator for health services in England. One of its roles is to ensure that Health and Social Care Act 2012 is implemented and a key focus of the Act is on integrated care. The Act imposes duties on Clinical Commissioning Groups (CCGs) to ensure that health services are internally integrated (within NHS provided services) and externally integrated (with health and social services provided by others) where they consider that it would:
1) improve the quality of the health services (including the outcomes that are achieved from the provision of those services),
2) reduce inequalities between persons with respect to their ability to access those services, or
3) reduce inequalities between persons with respect to the outcomes achieved for them by the provision of those services
Monitor has a responsibility not only to ensure that CCGs commission integrated care but can hold to account all NHS Services including commissioned voluntary sector organisations.
The word integration is open to interpretation but Monitor’s view is that:
- Integrated care is primarily about individuals’ experience of care and ensuring better outcomes through coordinated, person-centred care and support
- Integrated care is neither necessarily about structures, organisations and pathways, nor about the way that care is funded or commissioned; and
- Integration may refer to how services are configured to deliver seamless care, where the patient or user perspective is the organising principle of service delivery.
A rather more friendly version from National Voices (commissioned by Monitor) is that “Care and support is integrated when it is person-centred and coordinated” and, from a person’s point of view, that “I can plan my care with people who work together to understand me and my carer(s), allow me control and bring together services to achieve the outcomes important to me”.
This clearly has consequences for commissioning by CCGs. How will they procure services in a way that meet their duties under the Act? It is easy to make general statements about the importance of integration but this needs to be made practical through joint planning and joint commissioning (in Greater Manchester, Living Longer, Living Better is the big integrated Care Project) and also through procurement and the specifications and contracts for commissioned services. These specifications and contracts are also required to obey the NHS procurement regulations, a fine balancing act.
Monitor is vague about how this might be done, making a couple of suggestions, that providers should be asked to propose how they would cooperate with other providers or that they should be required to hold multi-disciplinary meetings (FAQs on integrated care). Generally they just say it is up to the CCGs to work out how to do it, whilst providing hypothetical case-studies that illustrate just how difficult it is to balance all the different requirements that CCGs must fulfil in making decisions about whether or not to go out to competition. It is arguable that competition and integration in many commissioning processes are mutually exclusive. If organisations are required to compete against each other for contracts how then are they then supposed to build up the long-term, stable and mature relationships needed for integrated services. Where a service is operating well and is well integrated with other services, why risk that service by putting it out to competition.
There is perhaps a way through the mire if the hurdles that procurement law put in the way are managed and commissioners decide to grasp it. The answer begins with the Act itself. Public bodies are allowed by procurement law to insert into their decision-making processes their own policies around best value, particularly where they are in accordance with national legislation.
Integrated Care is a requirement on CCGs. Long-term, stable and developed relationships are a requirement for integration, it can take many years, for instance, to develop working referral mechanisms and shared databases and, in reality, these are much more difficult to create than internal quality assurance measures. CCGs can make the decision to reflect the importance of integrated services properly both within their specifications and their bid scoring processes. They can shift the focus away from clinical quality and a narrow and unsophisticated concept of value for money, to one that balances these measures more fairly with integrated care quality and a whole value approach.
This is more likely to protect the existing organisations that have built up relationships and provide good quality services, against the cost-cutting newcomers with no local links. Thus, even if CCGs feel unable to avoid going out to competitive tender they can build in measures that protect the best of what they have, get rid of poorly performing organisations, and bring in new organisations who will have to demonstrate their track record of delivering integrated care.
Integrated care is not an added extra, it is the core of patient experience, the right to have joined-up services that all work together. Even more fundamentally it is about working with patients in a holistic way rather than as a bunch of unconnected conditions.