The Five Year Forward View sets the stage for integrated care models. However, it is not only care that needs to be integrated.
For the new models to truly flourish they need rock-solid foundations; there must be harmonisation of key assets, including estates, IT and equipment. What is really needed is an integrated platform.
The Five Year Forward View
There are seven main new models of care envisaged by the report. They all have ramifications for primary care but perhaps
the two most relevant are:
Multispecialty Community Providers (MCPs)
Primary and Acute Care Systems (PACS).
At its heart, this model envisages the formation of large group practices – federations or networks or single organisations. This is partly in response to the fact that the traditional GP model is changing with the increase in salaried and sessional doctors rather than partners. Points to note about this model:
- The aim is to target patients with complex on-going needs such as the frail and elderly or those with chronic conditions
- Larger Group Practices may for example employ Consultant Physicians or Consultant Geriatricians
- Federations could run local community hospitals – expand diagnostic services as well as maybe dialysis and chemotherapy
- Technology is key.
This is where the phrase “vertical integration” comes from. This model will allow single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services. Points to note about this model:
- In some circumstances – such as in deprived urban communities where local general practice is under strain and GP recruitment is proving hard – hospitals will be permitted to open their own GP surgeries with registered lists. Safeguards will be needed to ensure that they do this in ways that reinforce out-of-hospital care, rather than general practice simply becoming a feeder for hospitals still providing care in the traditional ways
- In other circumstances, the next stage in the development of a mature Multispecialty Community Provider (see section above) could be that it takes over the running of its main district general hospital
- At their most radical, PACS would take accountability for the whole health needs of a registered list of patients, under a delegated capitated budget – similar to the Accountable Care Organisations that have developed elsewhere.
There remains some uncertainty over how precisely this is to be funded. Enablement monies for vanguards will undoubtedly have a big part to play but so may the following:
- Primary Care Infrastructure Fund
- PM Challenge Fund
- Better Care Fund
So what are the estate consequences of integration?
Estates present potentially difficult issues for partners in an integrated care model – but also many opportunities. Presently, nobody knows the answers – but these are some of the issues:
One possibility may be operating from the same base or sharing several different buildings. This will need careful planning to ensure all stakeholders’ needs can be met and potential conflicts avoided. Flexible agreements can be drawn up allowing the stakeholders to use the pooled premises either at short notice or on a more permanent basis.
If sharing is permitted then there needs to be a clear understanding and demarcation about which organisation retains responsibility for issues such as:
- CQC compliance
- Repair and maintenance
- Statutory and regulatory compliance
Sell off surplus?
If estate rationalisation is possible as a result of integration then surplus property may be sold off. How to deal with the proceeds of sale needs to be clearly documented in advance. The proceeds could be used to:
- improve the remaining estate
- “pump-prime” new services
- fund new-builds such as step up/step down care.
Vertical integration – who buys the GP premises?
One consequence of vertical integration could be that some primary care premises such as GP surgeries may no longer be needed. In some cases one of the stakeholders may wish to acquire them but alternatively they may be sold on the open market. In the case of premises owned by the NHS this will raise questions about how proceeds of sale should be treated.
Are new premises needed?
In other cases, stakeholders may agree that new premises need to be acquired – for example, if services are to be co-located but no existing premises are suitable. Again, issues around funding a purchase or lease (and how on-going costs will be met) will need to be discussed and resolved by partners.
This is a significant enabler for integrated care. There will of course be different IT issues all over the country and so whilst it is difficult to generalise, the following points merit some consideration:
- What type of system is to be used? Is there to be one common one or several with linking “middleware”?
- Are there any intellectual property issues? Is it clear who is to own any particularly innovative solutions/processes that may arise?
- Are you confident that what you are doing complies with the provisions of the Data Protection Act?
Flexibility to move?
Do you have the flexibility? Are you bound into leases with onerous exit costs? Is it really as simple as saying that you all want to move into the local community hospital?