Lessons and Questions from Previous Research Relevant to Implementing the Integrated Resource

Lessons and questions from previous research relevant to implementing the Integrated Resource Framework in Scotland

Lessons

The IRF is about identifying and integrating the budgets (resources) for services provided to particular groups (clinical groups, age-based groups, geographical groups) from primary and secondary health care and from social care in the belief that it will lead to care with is better coordinated, in or close to people’s own homes and better value for money.

Integrated care can be achieved through a variety of organisational arrangements such as:

· Multiprofessional, integrated health and social care teams, working to shared goals and standards with staff employed by different organisations. They may be aligned around GP practices, or for specific conditions or care groups. These approaches have been common in Scotland over the last decade. They tend not to have a capitated, risk-adjusted, budget but to be planned or commissioned;

· Providers’ network in which organisations remain independent but work collaboratively to deliver agreed (contracted) services with other network participants;

· Single organisations that bring together all providers and also commission services as appropriate. This would mean organisations employ all health and social care staff and work to a capitated, risk-adjusted, budget.

Current evidence and analysis suggests that any of these organisational arrangements can work to integrate care but whether they are successful will depend on the extent to which people who make resource decisions, GPs, consultants, discharge nurses, care managers, patients and their family members (and so on) can change their current patterns of behaviour. This in turn, will depend on factors including:

a) the extent to which incentives for making particular resource decisions, and the governance arrangements in which they operate, are aligned to support shared goals and effective collaboration. A global budget for all services in the ‘bundle’ is the main mechanism, which needs to be capitated and risk-adjusted;

b) the potential for fragmentation with selecting specific conditions or services for integrated delivery (e.g. what does focussing on COPD do for people with multi-morbidity?);

c) the practical challenges of aligning goals, values and working patterns of professionals and patients employed in different organisations;

d) the level of development of integrated or linked information systems.

Commentators have identified a number of elements necessary to the successful achievement of integrated care. The existing evidence raises a number of practical questions for the test sites.

Questions

Please rate your current experience in each of the following areas. (You will not be asked to submit this paper so it is for discussion and your own learning)

Question / Score (1-10) / Learning/Action points
To what extent is your test site successful in developing capitated, risk-adjusted, budgets for the groups and care bundles on which you are focusing?
How well are these costs allocated across groups/geographical areas and adjusted for deprivation?
To what degree are these budgets contested or contestable?
To what extent are planners aware of, and planning for, potential unintended consequences?
To what extent are the clinical staff and care staff, who make resource use decisions, involved in the planning and detailed implementation of the test sites?
How developed are the information systems?
How well do the information systems operate?
To what extent is there clear leadership from elected members, NHS Board members and senior managers?
To what extent is there ‘bottom-up’ leadership?
How successful has your test site been in maintaining a focus on service users rather than on structures or organisational solutions?
How engaged are the front-line staff (GPs, consultants and other hospital doctors, care managers etc) who make resource use decisions and deliver integrated services to real people?
To what extent do front-line staff have real budgets and real accountability? (This could include the possibility to invest upstream with savings but also penalties with overspend. In the absence of an actual budget, then governance arrangements that allow investment and penalties should be considered.)
Add your own issue/question

Bibliography

Ham C. Only Connect. Policy options for integrating health and social care. The Nuffield Trust, 2009. http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=0&PRid=570

Lewis R, Rosen R, Goodwin N, Dixon J. Where next for integrated care organisations in the English NHS? The King’s Fund and The Nuffield Trust, 2010. http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=693

Mays N, Wyke S, Malbon G and Goodwin N eds (2001) The Purchasing of Health Care by Primary Care Organisations: An evaluation and guide to future policy. Buckingham: Open University Press.

Smith J, Curry N, Mays N, Dixon J. Where next for commissioning in the English NHS? The King’s Fund and The Nuffield Trust, 2010. http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=694

Smith J, Wood J, Elias J. Beyond practice-based commissioning: the local clinical partnership. The Nuffield Trust and NHA Alliance, 2009. http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=659

Smith JA, Mays N, Dixon J, Goodwin N, Lewis R, McClelland S, McLeod H and Wyke S (2004) A Review of the Effectiveness of Primary Care-led Commissioning and its Place in the NHS. London: The Health Foundation.

Weatherly H, Mason A, Goddard M, Wright K. Financial integration across health and social care: evidence review. Scottish Government, 2010. www.scotland.gov.uk/socialreserach.

Integrated Resource Framework Evaluation

Lessons and questions from previous research Page 3