Delivering integrated care - Practical Diabetes

Model of care
Delivering integrated care: a prime
contractor model
The NHS has made great progress
over the last few years in delivering
better services for patients, including
outcomes and reduced waiting
times. However, it has sometimes distanced
itself from the end; the concerns
that really matter to staff and
patients. Some of these concerns
have been expressed by members of
our Long-term Conditions Clinical
Programme Board. For example,
they want it recognised that they are
experts in themselves and should be
listened to. Their concerns are not
only clinical and they want to be considered
holistically. They resent the
use of language and knowledge as a
barrier, and want to be treated on an
adult-to-adult basis.
At the moment, the service is too
hospital based and paternalistic. The
present care model is insufficiently
personalised and lacks support for
self-care or shared decision making.
Customers perceive a variable service
quality and a lack of joined-up care;
i.e. a lack of integration between generalist
and specialist care, physical
and mental health delivery and medical
and nursing therapy. This coincides
with an increasing service
demand, coupled with an unprecedented
reduction in resources – in
short, the NHS needs to do much
better with much less. However, historically
the demand has not been
managed using the current levers.
Health care is recognised as a highly
complex business which is micromanaged
with little integration in
the process/care pathway/supply
chain. There is a lack of clinical and
financial management and accountability
across the pathway. And the
present specialist outpatient system is
a 19th century model and not the
way in which such care should now
be delivered. The present model of
controlling demand and delivering
savings involves primary care assessment
and treatment loosely managed
by QOF, and hospital assessment
and treatment with levers
managed from the outside such as
prior approval/pre-authorisations
and treatment thresholds (Figure 1).
Primary care
assessment and treatment
Quality and Outcomes
Framework
Figure 1. The traditional model – methods of controlling demand and delivering savings
Primary care
holistic assessment
and care
• Referral triage
• Skilling up primary
care
• Specialist assessment
Referral triage
Figure 2. The proposed new model
Referral
Prior approval/
pre-authorisation
Hospital assessment and treatment
Community
multidisciplinary
specialist service
(pathway hub)
Prime contractor
Pathway management
Hub functions:
• Specialist integrated
care
• Shared decision making
• Personal health planning
New/follow-up
ratios
Referral
Subcontracting
Treatment
thresholds
Highly specialised,
intensive, episodic
hospital care
• Supported self-care
• Patient & carer support
• Voluntary sector
provision
So the system has to change and,
in the East of England, a new model
has been proposed (Figure 2). In this
model, the current programmed
budget will be used to commission
joined-up services – an integrated
pathway hub (IPH) delivered by a
prime contractor. The prime contractor
is essentially a single provider
who will be given the total budget for
a programme, and will be accountable
for the quality and cost of the
entire patient pathway across primary,
community and acute care.
The prime contractor will provide
part of the care pathway – community-based
specialist services as an
alternative to hospital outpatients as
well as managing the rest of the pathway
through subcontractors. Unlike
the current model, the new integrated
pathway hub would not be
314 PRACTICAL DIABETES VOL. 28 NO. 7 COPYRIGHT © 2011 JOHN WILEY & SONS

Model of care
A prime contractor model
affected by Payment by Results and
would have a population-based
budget. The hub functions would
include referral triage, developing
primary care skills, specialist assessment,
specialist integrated care,
shared decision making, personal
health planning, supported self-care,
patient and carer support and a
voluntary sector provision.
The benefits of such a model
include a single provider who delivers
the commissioner’s requirements
across the whole pathway. The commissioner
contracts for stretching
quality and productivity outcomes,
and the IPH innovates and manages
all subcontractors across the pathway.
The model presents an opportunity
for real innovation, collaboration and
integration among providers delivering
‘joined-up care’ and is a truly
patient-centred service with the
opportunity for third sector and independent
sector provision in addition
to NHS provision.
Of course there have been challenges
and objections to such a concept:
vested interests in the status
quo, apathy, risk aversion, a lack of
vision and fear of competition.
However, despite these, this concept
Diary dates
z 16th FEND Annual Conference
9–10 September 2011
Atlantic Pavillion Tejo Hall, Lisbon, Portugal
Email: registration2011@fend.org
Website: www.fend.org
z 47th Annual Meeting of EASD
12–16 September 2011
Feira Internacional de Lisboa, Lisbon, Portugal
Email: secretariat@easd.org
Website: www.easd.org
z 43rd DPSG Meeting
22–24 September 2011
Queens’ College, Cambridge, UK
Website: www.mcb.uu.se/dpsg/
z ISPAD Conference
19–22 October 2011
Miami, USA
Email: ispad2011@kit-group.org
Website: www.ispad.org
z 39th Meeting of BSPED
9–11 November 2011
Mary Ward House, London, UK
Key elements
l The population-based budget will be
used to commission joined-up service –
an integrated pathway hub (IPH)
delivered by a prime contractor
l The prime contractor will provide
community specialist services as well
as managing the rest of the pathway
through subcontractors
l The IPH functions will include
developing primary care skills, shared
decision making, personal health
planning, supported self-care and
patient and carer support
l The new model is a patient-centred
service with the opportunity for third
sector and independent sector
provision
is currently being tested in the East
of England, where three pilot site
commissioners are being supported
to procure, via an open, competitive
tender process, a total of three
prime contractors/integrating pathway
hubs for respiratory health,
musculoskeletal health and the
health of the frail elderly.
Finally, it should be emphasised
that this model is in keeping with
Email: BSPED@endocrinology.org
Website: www.bsped.org.uk
z ABCD Autumn Meeting
11 November 2011
Hotel Russell, London, UK
Email: eliseharvey@redhotirons.com
Website: www.diabetologists-abcd.org.uk
z 7th National Conference of the
Primary Care Diabetes Society
18–19 November 2011
Hilton Metropole Birmingham NEC, UK
Website: www.diabetesandprimarycare.co.uk
z The Society of Chiropodists and
Podiatrists Annual Conference
24–26 November 2011
Harrogate International Conference Centre,
Harrogate, UK
Email: at@scpod.org
Website: www.feetforlife.org
z IDF World Diabetes Congress
4–8 December 2011
Dubai International Convention
Department of Health guidance
which states that: ‘...commissioners
could decide to tender some services
through competitive procurement to
a prime (single) contractor who
would then be responsible for co-ordinating
care, managing demand risk
(within reasonable limits), and
embedding choice of treatment and
setting, perhaps through sub-contracting
to other providers. Services
such as end of life and long-term
conditions (over and above those
elements provided as part of primary
care) might lend themselves to this
model. There is nothing to stop GP
practices from being part of these
provider-side integrated care arrangements,
for instance, as sub-contractors
to a prime contractor, as long as there
are appropriate safeguards in how the
services are commissioned.’
Charles Wroe (medical writer) wrote
the text based on a presentation from
Steve Laitner given at the Association
of British Clinical Diabetologists
Spring Meeting 2011.
Dr Steve Laitner, GP and Associate
Medical Director for East of England
Strategic Health Authority
and Exhibition Centre, UAE
Email: wdc@idf.org
Website: www.worlddiabetescongress.org
z Joint Meeting of ABCD
and the Renal Association
23 February 2012
International Convention Centre, Birmingham, UK
Email: eliseharvey@redhotirons.com
Website: www.diabetologists-abcd.org.uk and
www.renal.org
z Diabetes UK Annual
Professional Conference
7–9 March 2012
SECC, Glasgow, UK
Email: conferences@diabetes.org.uk
Website: www.diabetes.org.uk
z The Royal College
of Ophthalmologists Annual
Congress
15–17 May 2012
Arena and Convention Centre, Liverpool, UK
Email: contact@rcophth.ac.uk
Website: www.rcophth.ac.uk
PRACTICAL DIABETES VOL. 28 NO. 7 COPYRIGHT © 2011 JOHN WILEY & SONS 315