INTEGRATED CARE
Four lessons for contracting integrated care Dr Rachael Addicott, a senior research fellow at The King’s Fund, discusses her latest publication.
M
any clinical commissioning croups (CCGs) across England are starting to
consider how to use different contract models to encourage greater collaboration between providers at a local level. The ambition to collaborate and deliver more integrated care has driven many local developments over a number of years. However some of those at the forefront of these partnerships feel they eventually reach the boundaries of what is achievable within the structures of existing (and potentially conflicting) contract and payment models. As such, the range of contractual alternatives being discussed and implemented across the country is seen as an opportunity to overcome these restrictions.
Through this process however, the original purpose of delivering more integrated and coordinated care for patients can sometimes be lost in the technicalities of the contractual models. The King’s Fund report, ‘Commissioning and Contracting for Integrated Care’, outlines some of these models, attempting to clarify the broad structural innovations and how they are used in practice. What is clear from the evidence presented in the report is the importance of developing contractual solutions that meet the specific needs of local health systems and their patient populations – rather than starting with a model and working backwards to shoehorn providers and care pathways into the structure.
Commissioners (and others involved in contractual developments) should start by diagnosing the problem and then work together to identify an appropriate solution. The result will look different, depending on a number of factors, including the population segment, the local provider mix (and any gaps), the specific problems identified, desired clinical outcomes and the vision for delivery of care into the future. The process will also reveal whether there is a need to test the market through procurement.
Throughout the process, commissioners and providers should focus on four key things.
1) Engagement It is essential to continually engage and
communicate with providers, patients and the wider community to define the problem and identify appropriate solutions. Through this iterative and inclusive process, partners can develop a shared vision that sets out what they want care to look and feel like in the future, then work back from that point to build a model that meets these aspirations. This vision should focus on how the solution will solve the problem rather than the details of the contractual model.
2) Building trust
Whilst it is important to develop transactional and relational approaches, nurturing trust and building relationships between providers is just as important (if not more so) to successful integrated delivery of care. Contractual vehicles do not replace the need for high-functioning local relationships. In fact, the risk generated through contractual interdependencies reinforces the necessity to build and maintain trusting and transparent relationships.
3) Alignment of payment mechanisms and incentives
Inconsistencies in the way different providers are reimbursed and incentivised continue to reinforce fragmentation in the delivery of care. Recent guidance from Monitor presents an opportunity for variation and flexibility to overcome this fragmentation and develop new models, while innovative forms of payment are developing at a local level. Transformation in the provision of care requires a corresponding change in how this care is commissioned.
4) Governance and organisational models
Shifting more accountability onto providers through contractual models leads to greater independencies and risks for providers. As the model will not necessarily set out how providers should manage and share risk, they need to develop appropriate governance to do this. Working together, providers are best placed to develop inter-organisational forums and processes for decision-making and holding each other to account.
Stimulating greater collaboration and service
integration is the driver for contracting and commissioning in different ways. Although the contract provides the structure and accountability mechanism for integrated care, it does not automatically stimulate providers to share information, simplify care pathways or work together to deliver more coordinated care. Many of the problems patients and service users experience with their care relate to gaps between services and providers. Contracts should focus on holding providers to account for streamlining delivery of care across these gaps for the population or disease group in question.
These novel contracts are not in themselves a panacea or shortcut – the contract itself will not solve problems, develop integrated services or fix poor relationships.
These new contractual approaches rely heavily on procurement and supply chain management to design integrated delivery. Commissioners need to consider what investment they can make in developing and supporting new contractual models. If the government and other national agencies are keen to promote alternative contracting and commissioning vehicles, then commissioners need support to develop these.
Furthermore, it is likely that providers will require continuing support from CCGs and nationwide bodies in fulfilling their own emergent responsibilities around supply chain management and managing financial risk.
About the author
Dr Rachael Addicott has been a senior research fellow at The King’s Fund since 2007, where her portfolio includes research on system reform and models of governance and accountability in UK health care, including work on foundation trusts, provider failure and integrated care.
Dr Rachael Addicott FOR MORE INFORMATION
W:
www.kingsfund.org.uk/publications/ commissioning-contracting-integrated-care
national health executive Nov/Dec 14 | 45
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