The Five Year Forward View sets the stage for integrated care models. However, it is not only care that needs to be integrated.
It is vital that the service critical infrastructure – estates and IT – are fully joined-up to provide a firm base for the new care models to build upon. The consequences of this are not readily apparent yet.
That is partly because there will be such a wide range of issues depending upon the type of integrated care organisation (ICO) and its infrastructure plans. There is a spectrum of possibilities.
For example, contrast the differences between say a pop-up clinic (providing say elderly care services and social housing advice) adjacent to A&E for say six weeks against taking a new lease for three years in a new health centre. Identifying and addressing issues early on will help organisations move towards the infrastructure best suited to the services they want to deliver.
The Five Year Forward View
There are seven main new models of care envisaged by the report. Two models have generated a lot of interest amongst provider trusts:
- Multispecialty community providers (MCPs)
- Primary and acute care systems (PACS).
MCPs
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 partners and sessional doctors.
Points to note about this model:
- The aim is to target patients with complex on-going needs like the frail 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.
PACS
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.
What are the consequences for infrastructure?
It is difficult to provide clear answers without knowing what type of ICO we are talking about. If the organisation is a loose contracting arrangement between the stakeholders then that model may lend itself to fairly flexible estate solutions. Integrated care is the direction of travel for many NHS policies, including the vision outlined in the Five Year Forward View Contrast that with an ICO in the shape of a special delivery vehicle – an LLP for example with the stakeholders as members – and things become a little more involved given that this would be a brand new company with separate legal personality from the stakeholders.
There are however some generic thoughts to bear in mind:
Sharing?
Flexible agreements can be drawn up allowing the stakeholders to use each other’s pooled premises either at short notice or on a more permanent basis. This arrangement may work well when the premises are within the ownership of a stakeholder. However, more detailed consideration may be needed where a non-stakeholder is involved such as a private landlord.
Responsibilities
It is vital that it is clearly documented which organisation is to be responsible and accountable for things like:
- CQC compliance
- Repair and maintenance
- Statutory and regulatory compliance
- Security.
Sell off surplus?
If estate rationalisation is possible as a result of integration then surplus property may be sold off. What to do with the proceeds of sale needs to be clearly documented in advance – the proceeds could be used to improve the remaining estate or to “pump-prime” new services or to fund new-builds such as step up/step down care. Integrated care will have implications for estates and IT as well as models of care.
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.
Flexibility to move?
Moving to a new or different site, or sharing a building with integrated care partners, may be an attractive option for some. But it is rarely as straightforward as it may appear. Moving premises requires looking at a number of issues. A key one is likely to be whether the partners are free to move from existing premises without penalty. They may be tied into long term leases which could be costly to exit. Buildings built under PFI – either with or without ‘soft’ facilities contracts – may present even more of a challenge as these contracts may have decades outstanding. Foundation trusts will also have a register of buildings used for the provision of commissioner requested services. Changing the use of these or disposing of them may be more complex and may take longer.
Due diligence
Where NHS organisations are disposing or acquiring properties to drive forward integrated care, they should not forget the need to carry out a due diligence exercise. This is likely to cover many of the points above such as pre-existing leases and ongoing equipment contracts. Identifying the risks and downside of such changes will help organisations make informed decisions about estates matters.
IT
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? Do you have in place robust governance processes for the lawful sharing of data?
- How is the IT solution to be delivered? What are the procurement issues around that?
Conclusion
Just as there is no “one size fits all” integrated care model, there is no one single answer to the infrastructure issues. There are however three key steps that may help:
Step 1: Start early. Infrastructure can very often be overlooked and not addressed until late in the day – there is sometimes an assumption that “it’s there and we can use it…”. This is a fundamental error. The importance of the infrastructure cannot be overstated and it is very often the case that this work stream requires lengthy lead-in times. For example, works to premises may be needed so there are issues around identifying the contractor, working up a specification, and obtaining landlord’s consent. All these things can take time and it is far better to identify the issues now and plan accordingly than try to catch up at a later stage.
Step 2: The form of the ICO will be a huge determiner of the infrastructure issues that you are likely to face. Once you have settled on the form you can then begin to analyse the infrastructure issues more carefully.
Step 3: Identify the service critical infrastructure you need, establish who owns it and what the scope is for sharing it with other organisations.
Click here to read our newsbrief in full.
Full articles:
Seven day working: but will it really ‘work’?; Client spotlight: Pennine Acute Hospitals NHS Trust; New care models: the workforce issues; Healthcare startups.