Integrated care: one population, one budget

Frimley Health and Care’s integrated care system is a good example of what NHS England had in mind when it talked about an ‘evolved version of a sustainability and transformation partnership (STP)’ in last year’s Next steps on the five-year forward view document. But in fact, Frimley’s integration journey started long before that.

Frimley Health NHS Foundation Trust was born out of the acquisition by the former Frimley Park NHS Foundation Trust of the Heatherwood and Wexham Park Hospitals NHS Foundation Trust. And as long ago as 2015, one of the ICS’s clinical commissioning groups (Surrey Heath) was already planning a programme of health and social care integration for older people with long-term conditions and complex needs.

But the creation of the STP, and its selection last year as one of eight shadow accountable care systems (now rebadged as ICSs), has increased the momentum even further. Final confirmation of Frimley’s operational status as an ICS could happen in May, although this requires all involved organisations to sign up to a system control total – which itself is dependent on NHS Improvement issuing final rules on how this will operate.

However, there are already signs of improvement from a more integrated approach in terms of getting a grip on demand. And there are some very visible signs of the increased collaboration that has brought the system this far.

These include last summer’s appointment of Nigel Foster (pictured) as director of finance and information management and technology at Frimley Health. He was previously chief finance officer for the three local East Berkshire CCGs (now formally merged into one CCG as of April) and retains this role – thought to be the only example of a shared provider/CCG director of finance role in the country.

The goals for the system could be lifted from any number of STP plans around England. It wants its population to have the ‘best possible health and wellbeing’ and to keep them ‘healthy and in their homes for longer’.

Like other STPs, it has identified a ‘do nothing’ gap – the system deficit it would face by 2020/21 if service models remained unchanged and demand and activity continue on trend. In Frimley’s case, this upfront calculation in 2016 amounted to £236m across health and social care. To address this, the ICS is bringing together statutory bodies including local authorities, three principal providers and three CCGs (Surrey Heath, North East Hampshire and Farnham and the new East Berkshire), with an initial focus on seven transformation initiatives.

Some might point at the providers’ relatively stable financial position as the foundation for its good progress to date and some early success. NHS Improvement’s Q3 figures showed all three of the main providers forecasting a surplus for 2017/18, with surpluses in two of those cases being more than plan.

Mr Foster acknowledges that ‘solid finances clearly help’, but says Frimley Health’s underlying position is much more challenging. In 2017/18, the trust was still benefiting from £15m of non-recurrent support related to its earlier acquisition. This income stream has now significantly reduced.

But a good financial base is only part of it. ‘The thing that makes all the difference is the level of trust and the quality of the relationships we have across the system,’ he says. ‘If you don’t have that, you won’t progress as far or as fast.’

Common cause

Relationships across Frimley weren’t always good – the system exhibited relatively adversarial relationships in the past. But the need to find a system solution for Heatherwood and Wexham Park marked a change in approach.

‘Previously, there had been no great rationale for lots of conversations between CCGs across the patch,’ Mr Foster says. ‘But this gave us a common cause and reason to come together to develop a standardised approach to commissioning and contracting from the acute trust.’

This also meant there was an established footprint to work from when STPs came along, with a logic based on a common primary flow of patients into the acute provider Frimley Health. ‘We’ve spent a lot of time developing relationships, perhaps especially with local authorities – they’ve been in the room from the outset with representatives on the ICS board and on the finance reference group,’ says Mr Foster.

An integrated care system does not mean everything is decided together – or that there is one single model in all parts of the economy. ‘Surrey Heath, for example, is continuing to work on integration and doing so very successfully – it is not in competition with what we are trying to do,’ says Mr Foster.

There is also clarity about what is best done together and what individual organisations just need to get on with. ‘Most of the things an acute trust has to do, it can just get on and deliver – debating them on a system level doesn’t add any value,’ he adds.

But for issues such as pathway redesign and ensuring organisations remain viable within transformed models of care, a system approach makes perfect sense.

Decision-making hubs

One key initiative is the development of integrated care decision-making hubs, building on existing work in local CCGs and North East Hampshire and Farnham’s Happy, healthy, at home vanguard. This has seen community multidisciplinary teams managing people with a high risk of hospital admission and the creation of multidisciplinary assessment and rehabilitiation centres and hospital in-reach services.

The ICS has also taken a system approach to clinical variation, pursuing its headline opportunity areas identified by the RightCare programme. For example, Frimley is implementing a new neurology service across its whole system, providing proactive and reactive support to patients to enable them to live as independently as possible.

There are some positive signs that all its initiatives are bending the demand curve on hospital services. Recent figures suggest that there have been reductions in A&E attendances, non-emergency admissions and GP referrals across most of its commissioners. Some of these are significant – a 10% reduction in GP referrals from Surrey Heath, for example, and a 4% reduction in A&E attendances in the former Windsor, Ascot and Maidenhead patch. And the system believes that it can continue to control this demand in 2018/19.

Funding flows need to underpin these new models as current payment systems will not always support revised pathways. For example, more proactive community support may reduce hospital admissions. But reducing the hospital’s payment using tariff (activity x price) would not recognise any fixed costs the hospital could not eliminate.

‘We all recognise that not all the payment by results costs can be taken out, and conversations are about what represents a genuine cost saving and what are reasonable challenges in terms of efficiency improvement,’ says Mr Foster.

However, he says the system has ‘moved away from thinking about spending a lot of time devising a new complex payment system’, suggesting this would be ‘almost a distraction from the main challenge’.

‘So we will continue to turn the tariff handle,’ he says, ‘as that is the best point of reference everyone has for pricing activity and services across the system.’ This will provide a starting point for conversations about what is affordable and what is needed – and all within the context of meeting its newly set system control total.

Frimley, like many other ICSs and STPs, does talk about moving towards ‘one budget’, although this is currently more figurative – getting best value out of the £1.7bn spent on health and care – than literal.

Mr Foster acknowledges there are different views on how this might move forward. ‘My view is we need to explore the idea of one budget – but it is not the main thing,’ he says. ‘The priority is keeping trust and relationships going. There are already enough ways to move money around the system between organisations – and we don’t even need a system control total for that.’

However, he acknowledges that in more financially challenged systems, more formal funding flows may be important.