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Integration need not stop at clinicians and service professions. For example,

Community Health Centers in America have been developed to integrate primary

care services with health promotion programmes, prevention programmes and

community development initiatives. Community Health Centers are estimated

to save $1,263 per patient per year compared to traditional primary care

provision. They also have 64 per cent lower rates of multi-day hospital admission

in comparison to non-health centre patients and one quarter of the total inpatient

bed days. Health centres such as these build on the extant community capacity,

to become essentially a rewired community support system; so community

health not clinical health.

This is particularly important in rural, sparsely populated areas where the cost

of delivering services over an area of low population density is a big driver

towards better supported stimulation of local, voluntary provision. Many of these

examples could be developed, but would naturally require a commitment from

multiple partners to fund the enterprise. But, as we have highlighted, the current

system remains woefully fragmented - in part due to the funding mechanisms.

Some have suggested capitation - i.e. the payment for services on a per

capita basis, as opposed to payment by activity - as a way to encourage a

more holistic approach. Croydon is among areas looking at implementing an

outcomes-based capitation model for commissioning services for those over

65.107 This would, of course, represent an utterly fundamental shift in the NHS

payment system so it will be interesting to see what comes out of the NHS

Integrated Personal Commissioning programme, which is looking to pilot such

an approach.108

What is perhaps more realistic in the medium term is, as one HWB Chair

suggested: "a five-year programme of investment shift, with overarching focus

on early intervention and prevention". We know this is achievable because

they have done something similar in Kent through the work of the Kent Health

Commission, where local health and care partners agreed to a 5 per cent shift

in preventative care.109

What would this look like? One approach would be to budget by age groups

and then commission them jointly, though care would be needed to ensure that

it did not cut across existing integration efforts.

To tackle the two most important age groups that would benefit the most from a

whole system approach, this could be: 1) single commissioning budget focused

on prevention around the 40-55 age group; 2) single commissioning budget

focused on care provision for 85+ year olds. This pooled budget approach

has got huge potential to promote truly integrated care and eliminate perverse

incentives. However, steps must be taken to ensure that decisions are not shaped

by short-term 'political' drivers and instead focus on the long term.

Recommendation: Introduce single, place-based commissioning

budgets for 1) prevention work for 40-55 year olds; 2) care

provision for those over 85 - accountable to strengthened Health

and Wellbeing Boards - as part of the ongoing integration of health

and social care budgets.

Recommendation: Review of wider funding mechanisms and set a

five-year timetable for complete NHS Tariff review.

107 Barnes, S, "Croydon CCG

creates £1.7bn plan for health

and social care services" LGC (9

October 2014)

108 NHS England, "NHS and social

care bodies take next step

towards integrated health and

social care for individuals" (4

September 2014)

109 County Councils Network, CCN

submission to the Health Select

Committee public expenditure on

health and social care (February

2014)

Chapter 4 - What Are Our Proposed Solutions?

33

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