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
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
108 NHS England, "NHS and social
care bodies take next step
towards integrated health and
social care for individuals" (4
109 County Councils Network, CCN
submission to the Health Select
Committee public expenditure on
health and social care (February
Chapter 4 - What Are Our Proposed Solutions?