New thinking is needed to increase local care for patients

BMJ 2008; 336 doi: (Published 24 April 2008) Cite this as: BMJ 2008;336:907
  1. Zosia Kmietowicz
  1. 1London

    The government needs to rethink the way it funds hospital care if patients are to be looked after closer to their homes, says a report out this week.

    The system of payment by results, which has been gradually introduced into hospital trusts over the past four years as a means of linking payments to activity, may actually hamper government plans to deliver care closer to patients’ homes, says a working party made up of representatives from the Royal College of Physicians, the Royal College of General Practitioners, and the Royal College of Paediatrics and Child Health.

    Instead of the block payments hospitals used to receive to provide certain services, payment by results means that money follows patients and allows those hospitals with greater throughput to earn more.

    But “perverse incentives” at the heart of payment by results can make it seem easier financially to admit patients rather than manage them outside hospital by means of specially commissioned specialist services in primary care.

    These types of disincentives “need to be rebalanced to support integrated specialist and generalist care closer to home,” says the report.

    For integrated care to work, boundaries between primary and secondary care need to be removed so that hospital doctors and general practitioners can work together in the patient’s best interests.

    The report believes that Teams without Walls, its model of integrated care, can deliver the high quality, cost effective care demanded by patients with long term conditions whose need for healthcare services changes throughout their lives.

    Under the model the teams design and commission service pathways rather than isolated blocks of care. To make the concept work, the department of health should consider a new model of payment by pathway for an episode of care, and annual payments by condition for long term conditions, says the report.

    “A jointly commissioned model of integrated health services provided by primary and secondary care would significantly reduce unhealthy competition between the two and reduce the potential for contractual and cultural conflicts between PCTs [primary care trusts] and hospital foundation trusts,” says the report.

    “This approach may challenge some of the recent NHS reforms, but promises to be a more sustainable solution to some of the entrenched problems the NHS must overcome if it is to succeed in the long term,” it adds.

    Clinical integration would also prevent hospitals expanding into the community and creating a monopoly. Surveys of good practice show that leadership and involvement of doctors is a key to successful integrated care.

    One such scheme for patients with inflammatory bowel disease in Barnsley led to estimated savings of £40 000 a year, freed outpatient slots, and provided relapsed patients with rapid advice. Under the scheme, patients were taught to manage their condition without going to hospital if they were stable, and results of blood test monitoring and advice were sent by email or text.

    Simon Lenton, vice president for health services at the Royal College of Paediatrics and Child Health, said the report “illustrates the power of clinical collaboration to redesign and improve the patient experience and outcome of services. The future challenge is to align management structures, healthcare financing systems and commissioning strategies to promote this type of collaboration.

    “Patient care needs to be delivered by teams based on pathways within managed networks, unconstrained by traditional or organisational boundaries.”


    • The report, Teams without Walls—The Value of Medical Innovation and Leadership, can be seen at

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