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Payment reform needed to promote integrated care, says Nuffield Trust

BMJ 2011; 343 doi: (Published 07 July 2011) Cite this as: BMJ 2011;343:d4318
  1. Jacqui Wise
  1. 1London

Radical models of payment across clinical pathways, such as global capitated budgets, should be piloted to encourage integrated care, a report from the Nuffield Trust says.

With global capitated budgets a provider is given a total budget for a defined population to maintain health and provide services in order to reduce costly hospital admissions.

The trust’s report, Integration in Action; Four International Case Studies, is based on a detailed study of four separate organisations in Europe and the US that have made good progress integrating health and, in one case, social care services. The report concludes that good governance, leadership, and information technology are all needed for greater integration in healthcare.

The report welcomes the plan to develop “best practice pathways,” using evidence from the National Institute for Health and Clinical Excellence (NICE), which will be built into standard national contracts used by clinical commissioning groups. But it says the NHS Commissioning Board should support local commissioning groups to develop new ways to commission integrated services. Local organisations should be allowed to develop bundled payments and local tariffs for key conditions and pathways.

It calls for an audit of all current methods of paying for clinical care to see the extent to which they encourage integrated care for people with chronic, complex health and social needs. Monitor and the NHS Commissioning Board should work together to develop a pricing strategy to incentivise integration where it provides better quality and more efficient care.

Rebecca Rosen, one of the authors of the report and senior fellow at the Nuffield Trust told the BMJ: “The current payment by results system in the acute sector is an incentive to do more activity and a disincentive to working collaboratively with the community. The challenge is to produce bundled payments or systems of currency that cover the entire patient journey. This will encourage services to work together and produce the best possible care for the patient in a lower cost environment.”

She said that a sum of money could be allocated for a whole pathway of care or for a whole disease group such as diabetes. She added that any savings made could be distributed among those delivering the care so producing incentives to everyone to work in a high quality way keeping patients as well as possible.

The report also found that targeted micro-incentives can support integration. These are already in use in primary care with the Quality and Outcomes Framework (QOF) and in acute trusts with the Commissioning for Quality and Innovation Payment Framework. The report suggests that they could be further developed to support the goals of integration.

Dr Rosen says Monitor needs to develop a regulatory framework that allows GPs, acute hospitals, and community trusts to work together if they can show that it will benefit patients. She said: “We have a real window of opportunity here as long as we can get the regulatory system and the payment system to support working together.”

The report analysed four organisations that were relatively young in their development of integrated care and had characteristics that were similar to the NHS. They were Community Care North Carolina (CCNC), a government funded network that aims to improve access and quality levels for Medicaid beneficiaries; Greater Rochester Independent Practice Association (GRIPA), an independent practice association in upstate New York; Regionale HuisartsenZorg Huevelland (RHZ), a Dutch organisation providing support to GPs to deliver integrated diabetes care in the Maastricht region; and North Lanarkshire Health and Social Care Partnership, an NHS and social care partnership in Scotland.


Cite this as: BMJ 2011;343:d4318


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