House of Commons - Managing the care of people with long-term conditions

Managing the care of people with long-term conditions - Health Committee Contents

4 Managing the system to deliver better care for long-term conditions

Why change the present mix of services?

118. We noted above the broad consensus that a national health service designed to provide acute services to treat single episodes of care is now increasingly required to provide complex treatment to people with long-term conditions. There is a prevailing view about the direction of travel required which, put broadly, holds that better-quality care, at better value to the health and care system, can only be delivered to people with long-term conditions if health and social care services are more integrated, and if there is greater emphasis on preventative services, early interventions and community-based services rather than acute services.[142]

119. We sought evidence on the scope for a variation in the present mix of health and care services, and received substantial corroboration of this view. The Department of Health and NHS England suggested that effective treatment of long-term conditions could take place outside hospitals: early diagnosis could reduce emergency attendances at A&E departments and emergency admissions to acute hospitals, and care management for those with long-term conditions which was properly coordinated and integrated could reduce the use of acute services.[143] The Nuffield Trust pointed out that any transfer of services from the acute sector would require effective community health services and good-quality primary care.[144]

CHANGING THE SERVICE MIX: MANAGING AMBULATORY CARE-SENSITIVE CONDITIONS

120. One proposal for change to the service mix involves the treatment of chronic ambulatory care-sensitive conditions (CACSCs). The Department of Health told us that of the additional £4 billion of annual cost pressure on the NHS expected by 2016, the majority was attributable to "continued inappropriate and unplanned use of expensive acute hospital services", and indicated that NHS England would "need to work with partners to shift spend to support more primary and community based care and prevention."[145] It considered that many attendances at A&E departments and emergency admissions to hospital could be avoided by better management of "those with conditions sensitive to ambulatory care".[146] The mandate to NHS England includes a specific measure designed to ensure that more such conditions are normally treated outside hospital: indicator 2.3.i of The Mandate tracks the rate of unplanned hospitalisation for chronic ambulatory care sensitive conditions in adults.

121. The Department defines chronic ambulatory care-sensitive conditions (CACSCs) as "those where the right treatment and support in the community can help prevent people needing to be admitted to hospital."[147] The Nuffield Trust defined them as "clinical conditions for which the risk of emergency admission can be reduced by timely and effective ambulatory care, meaning mainly primary care, community and social services, and outpatient care."[148] As such the conditions are defined by whether they are considered treatable by primary and community health and care services, and measuring rates of unplanned hospital admissions for CACSCs can therefore indicate the adequacy of local community and primary care services in providing routine management for such conditions.[149]

122. Nuffield Trust research has indicated a steady increase in annual rates of emergency admissions for CACSCs between 2001 and 2011, even when figures are adjusted to take account of demographic change.[150] A number of reasons are suggested for the overall increase, including changes in hospital admission procedures and changes in the underlying prevalence of the disease. A further reason given is the perceived lack of alternatives to inpatient care for such conditions: social care may be inadequate or community-based alternatives to hospital treatment lacking.[151] In this area, however, reliable evidence on the impact of local and national health policies on the quality and cost of community services was lacking and required "much more comprehensive, independent and transparent analysis".[152]

123. Data collated by The King's Fund from Hospital Episode Statistics for 2009/10 indicated that all ACSCs (i.e. chronic, acute and vaccine-preventable) accounted for one in every six emergency hospital admissions in that period, and cost commissioners £1.42 billion.[153] Of the chronic ACSCs, chronic obstructive pulmonary disease (10%), asthma (10%), angina (9%), congestive heart failure (7%) and diabetes complications (6%) accounted for 42% of emergency admissions for all ACSCs.[154] These conditions between them accounted for 41% (or £582 million) of the overall tariff cost to commissioners of such admissions.[155] Costs were amplified in older age groups, an occurrence explained by the likely greater incidence of co-morbidities and complex conditions in such age groups. Measures proposed to reduce the incidence of such admissions in the short to medium term included better management of ACSCs in primary care, and CCGs were encouraged to examine the admissions data of their constituent practices to understand where variations in admissions were occurring and why.[156]

124. Judith Smith explained why the treatment of such conditions was in particular focus:

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When pressed on the rationale for advocating a reduction in hospital admissions for such conditions, she stressed that effective interventions were assessed by both their quality and their cost-effectiveness.[158]

125. Dr Sue Roberts suggested that a focus on the reasons for treatment in secondary rather than primary care was rather missing the point:

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Martin McShane, of NHS England, appeared to concur:

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Our view

126. Ensuring that more patients with chronic ambulatory care-sensitive conditions are treated in primary care or in community settings, rather than in acute hospitals, may yet prove to be an important component of the Government's plan for management of long-term conditions in the health and care system, not to mention a strategy for reducing the costs of the acute sector. We nevertheless consider that it is an error to regard a greater volume of treatment of CACSCs in the community as a worthwhile outcome in itself: what matters is whether such treatment results in better outcomes for the patient.

127. In its Mandate to NHS England the Government identifies the level of unplanned hospitalisation for CACSCs as an indicator for progress in the overall improvement area of reducing time spent in hospital by people with long-term conditions. We are not convinced that this is the most appropriate indicator to select, though we recognise that it may be the only one readily available. In our view, the focus of changes to the health and care system in management of long-term conditions ought to be on the provision of personalised services which treat the whole person, enable active self-management and mitigate the adverse effects of the condition to enable the person to have as active a life for as long as possible. If that objective is pursued, then it ought to follow that unplanned admissions to hospital will reduce: but the reduction in admissions to acute care should be the happy consequential outcome of a system which manages the care of people with long-term conditions better, not the yardstick against which progress is measured.

128. We doubt whether necessary change in health and care provision for the long term will be achieved through measures which merely address the symptoms of poor management of many chronic ambulatory care-sensitive conditions, namely excess unplanned admissions to acute providers. The priority for the Department of Health and NHS England should be to address the underlying structure of services and incentives which send so many patients with CACSCs to acute care in the first place.

LONG-TERM CONDITIONS IN PRIMARY AND COMMUNITY CARE

129. The NHS Confederation told us of the "widespread agreement" that, where clinically appropriate, increasing the care given to people with long-term conditions in the home and in the community was "the right approach" and provided more effective support. A 2012 survey of Confederation members indicated that 63% believed that a move of services from acute care was a priority. The Confederation also reported a Department of Health survey of members of the public in 2012 which found that 66% of those polled agreed that moving services into the community could raise standards.[161]

130. Many witnesses provided evidence of the effectiveness of local changes in service mix in the treatment of long-term conditions. The NHS Confederation and the Nuffield Trust both highlighted the example of the North West London Integrated Care Pilot, launched in June 2011, which piloted a multidisciplinary approach to the coordination of care for a population of 550,000 people, with a focus on integrating care for people older than 75 years and people with diabetes. In both cases the populations were experiencing variations in the provision of care and a high level of avoidable admissions, and in both cases the outcomes were readily measurable.[162]

131. In North West London the pilot involved over 100 general practices, two acute care trusts, five primary care trusts, two mental health care trusts, three community health trusts, five local authorities and two voluntary sector organisations with a specific focus on the conditions in focus.[163] Clinicians across the participating organisations worked together in multi-disciplinary groups to assess the relative health risks to the populations under consideration ("risk-stratification"), to develop shared protocols for treatment, to develop care plans for patients and hold case conferences for patients with particularly complex needs or problems, and to identify the care available and the gaps in provision. The pilot was funded with £7 million from the London Strategic Health Authority, using funds which would otherwise have been spent on payments to acute trusts under the 30% tariff payable on excess emergency readmissions.

132. The overall aim of the pilot was to deliver integrated services to the whole population, focusing effort on the 20% of the population identified as being responsible for 80% of the cost of health and care services. The NHS Confederation reported that some benefits from the pilot had been identified early on, though others would be realised over a period of between five and 10 years.[164] Based on the impact to May 2013, the pilot "hopes" to reduce emergency admissions for people over 75 with diabetes by 10%. Better patient experience of coordinated care across providers has also been reported.

133. The Confederation also drew attention to the results of a smaller-scale initiative in Hammersmith and Fulham, where a community-based team had been set up to improve care for those with chronic obstructive pulmonary disease (COPD). This community services provided rehabilitation services, community clinics, specialist support for primary care, support for patients following discharge from hospital and support for self-management of the condition. The benefits attributed to the programme included a saving of £170,000 in the cost of first and follow-up appointments, a reduction in hospital admissions for COPD by 19% and a reduction in readmissions by 66%.[165]

134. Dr Judith Smith, of the Nuffield Trust, suggested that most patients—including those with long-term conditions—would rather be treated closer to, or in, their homes in preference to inpatient or outpatient treatment in hospital.[166] Professor Alan Maynard was not so certain: for some episodes of care in the course of management of certain long-term conditions, treatment in an acute hospital would clearly be the most appropriate course of action.[167] We received a submission from the Pemphigus Vulgaris Network expressing great concern at any proposal which might result in treatment for this serious skin condition being provided outside specialised secondary care settings.[168] Baroness Young, of Diabetes UK, also expressed reservations about a wholesale transfer of all diabetes services to the primary or community sector.[169]

135. While the prevailing assumption may be that people with long-term conditions would welcome treatment being provided through community or primary care as close to home as possible, this approach should not be taken for granted in the design of systems to support the management of long-term conditions. Many conditions will continue to require treatment to be provided being provided in specialised secondary care settings.

136. Alan Maynard challenged the present policy assertion that care for long-term conditions could be better provided in the community via integrated pathways of care, in ways which offered better quality, improved outcomes and potential savings in cost. He argued that in "practically all public and private health care systems" the incentives and fragmented systems of care delivery tended to weaken commissioners, with the result that in many cases the policy ideal—transfer of care for long-term conditions from the acute sector to community care—would not be achievable: community care would come to complement, rather than replace, acute services. Without the power to demand reductions in hospital capacity and the money to pay GPs to increase the care they provided, commissioners would have little power to influence the prevailing pathway from the GP to secondary care.[170]

137. There is evidence to indicate that poorly-planned changes to service mix have not in the past had the desired effect. The British Association of Dermatologists (BAD) reported that some dermatology outpatients services had been decommissioned, to be replaced by community-based services which provided care closer to home for dermatology patients. However the expected improvements in service provision had not been realised and there had been increased referrals to both community and acute services. BAD feared that changes in commissioning arrangements and the introduction of commissioning from "any qualified provider" had resulted in the "fracturing" of care pathways. This had meant that there was no net reduction in the cost of treatment when compared to acute care: in fact overall costs increased because patients were often "lost" in referrals from their GP to a community care service. BAD was also concerned that primary care services were "buckling" under current levels of demand.[171]

THE EVIDENCE FOR BENEFITS

138. We have received a great deal of evidence of the benefits of a change in the mix of services for long-term conditions, which we describe elsewhere in this report, and we have heard a number of persuasive arguments from common sense. We nevertheless note that on the existing evidence the clinical case for change is rather stronger than the economic case. The NHS Confederation told us that a shift of care from acute services into the community and into the home "will improve the quality of care provided to patients with long-term conditions and has the potential to save money."[172]

139. Dr Peter Aitken, of the Royal College of Psychiatrists, painted an attractive picture of integrated services in operation:

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140. Professor Alan Maynard took a more sceptical view of the potential benefits of large-scale service change:

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He expressed some scepticism over the evidence for the effectiveness of the House of Care model:

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141. Professor Maynard pointed out the challenge for commissioners seeking to improve outcomes for people with long-term conditions who are considering changes to the mix of services being commissioned:

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142. Dr Judith Smith of the Nuffield Trust concurred on the adequacy of the evaluation of previous experiments with shifts to community care:

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She noted that the evidence for benefits in terms of patient experience and outcomes was stronger than the evidence for economic benefits.[178] Although there was evidence that integrated care structures in places such as Torbay had reduced the demand on acute services, it was difficult to attribute the reduction in demand on acute services specifically to the change in service mix.[179] She suggested that a study of at least five years was necessary to demonstrate genuine benefits to patient outcomes and demand on services:

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143. Dr Sue Roberts was not surprised at the lack of evidence for benefits, suggesting that the methods of evaluating changes in service mix did not appreciate the scope of the change contemplated:

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144. Dr Peter Aitken called for frequent evaluation of new interventions to manage long-term conditions:

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145. Dr Karen Lowton of King's College London raised a related issue of the design of future models of care for young people with one or more rare and complex conditions. They were increasingly ageing successfully, because of medical advances and changed in social attitudes, but there was no evidence base to indicate how services for such people should be configured to give optimal care:

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Our view

146. During the course of this inquiry we have not received any evidence to indicate conclusively that a large-scale change in the mix of health and care services for long-term conditions—in essence, a shift from the acute sector to the community sector—will achieve either the improvements to the physical and psychological well-being of people with long-term conditions or the benefits to the health and social care budget that some have claimed. There is nevertheless sufficient evidence to indicate that a change in service mix may well deliver outcomes—such as support for better self-management, more responsive care from community-based services, and less reliance on referrals to the acute sector— which will benefit people with long-term conditions.

147. As Dr Sue Roberts pointed out to us, that the absence of evidence does not necessarily mean that such a change would not be effective.[184] The experience of integrated care trusts in England, and vertically-integrated care organisations overseas, suggests that such a change may well be effective. Yet to commissioners and providers who are under financial strain and facing demands to do more with less, the risks of undertaking substantial changes in the service mix without reasonable assurances that such changes will deliver better outcomes and greater value for money may not be an attractive prospect.

148. As our witnesses indicated, the gathering of empirical evidence on the effectiveness of change can be hampered by short-term approaches to modelling interventions and evaluating outcomes. There is a clear financial incentive to prioritise the benefits which can be achieved tomorrow from quick fixes over the merits of investment in, and sustained support for, more difficult but ultimately beneficial changes which guarantee fewer rewards in the short term. In the light of the current demographic and financial pressures facing the health and care system, many may argue that system change cannot await the outcome of lengthy trials and detailed evaluations. To that argument we respond that while the results of demonstration projects and pioneers can win acceptance for the principle of change, they cannot substitute for a coherent change programme based on sound analysis. Pilot projects may demonstrate whether concepts are feasible and new ways of working can achieve benefits, but they are not primarily designed as trials.

149. Robust evidence on the long-term clinical effectiveness and cost-effectiveness of large-scale changes to the mix of services for long-term conditions is lacking. We consider that such evidence is vital to making the case for, and informing the design of, any form of sustainable service change which is to command widespread support. We therefore recommend that NHS England commission sufficiently rigorous studies of the effectiveness of services for people with long-term conditions which are delivered through integrated models of care, and that the outcomes for health and for cost-effectiveness across all settings are regularly and rigorously evaluated.

Commissioning services for the care of people with long-term conditions

150. There is no unified structure in England for the commissioning of services for the treatment of long-term conditions.

· Most acute care services and primary care services in community settings are commissioned by clinical commissioning groups, having regard to priorities set by local authority health and wellbeing boards.

· Primary care services delivered through GPs are de facto commissioned by NHS England within the framework of the National Health Service (General Medical Services Contracts) Regulations 2004[185], as amended, and under the directions collectively known as the NHS Primary Medical Services Directions, negotiated annually between NHS Employers and the General Practitioners Committee of the British Medical Association.

· Specialised services for long-term conditions are commissioned directly by NHS England.

We received evidence to suggest that commissioning responsibilities for certain conditions were not wholly clear and were dependent on the publication of detailed commissioning plans for specialised services by NHS England. The MND Association was concerned that the scope of service specifications for long-term neurological conditions had not been developed by NHS England in May 2013, and that there was a consequent risk that services which NHS England subsequently decided not to support through specialised commissioning would not have been included in local CCG commissioning arrangements.[186]

151. In addition, local authorities will provide or commission social care services to support those with long-term conditions eligible for such support. ADASS told us that they were working with The King's Fund to produce guidance for health and wellbeing boards in integration such activity: they suggested that it was necessary for local authorities to engage with health service commissioners and providers across all local settings in order to ensure that resources were effectively pooled to facilitate the commissioning and design of new services "with a clear understanding of the sheared improvement agenda".[187] ADASS stressed that integrated services for the support of people with long-term conditions "must be designed from the bottom up, designed around integrated health and care personal support plans and the pathways of people through a local health and care system."[188]

152. The Department of Health indicated that the NHS would support effective local commissioning for long-term conditions by:

i. "Working with Monitor to develop currencies and prices that support improved outcomes for people with long-term conditions;

ii. Establishing successful networks and partnerships with the third sector, social care and user organisations;

iii. Supporting CCGs and other partners at local Health and Well Being Boards (HWB) to address the prevention of LTCs in partnership with Local Authorities and local community action."[189]

153. The Department also indicated that NHS England would work to spread best practice, and gave an example from the Wirral where an admissions prevention service had been commissioned to reduce GP referrals to hospital for urgent care and admission rates to residential care from acute care. The benefits of the service, as reported by the Department, were "improved service user assessment", where providers agreed goals and outcomes; a shift to supporting people at home; and better value for money from better use of existing partnership resources.[190] The partners in the National Collaboration for Integrated Care and Support would be encouraging local commissioners "to innovate and experiment in ways that will deliver integrated and joined-up care and support at pace and scale", not least through the 14 "integration pioneers". The NHS would use "policy and commissioning levers to support management continuity" and would "build [. . .] on the GP practice to support relational continuity." The approach would be supported by the publication of NICE quality standards for long-term conditions.

154. The NHS Confederation stressed to us that a "collaborative, whole-system approach" was needed to support people to manage long-term conditions: "CCGs cannot do this alone. They need to be supported at system level to work with local authority commissioners and NHS England."[191] Arthritis Care suggested that assistance to commissioners must be based on "a good understanding of the realities" of commissioning services for long-term conditions, but that commissioners themselves ought to examine how they could improve condition-specific services: "the services for each condition needs to be looked at to see how it can improve, offer better value for money, and integrate better with other services."[192]

PRACTICAL SUPPORT FOR COMMISSIONERS

155. In our call for evidence we asked for examples of practical support given to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions. For some conditions—for instance diabetes,[193] epilepsy,[194] dermatological conditions[195] and rheumatic conditions[196]—it appears that there is a wealth of third-party guidance and support available for commissioners who wish to improve the design and delivery of local services. Charities supporting those with neurological conditions have established Neurological Commissioning Support (NCS) to work with commissioners to map neurology services, identify and analyse service gaps and help in the development of appropriate services.[197] The British Society for Rheumatology (BSR), Arthritis Care and the National Rheumatoid Arthritis Service have, with Department of Health funding, formed the Rheumatology Commissioning Support Alliance "to support commissioners and develop tools to demonstrate how better services for patients and better value for the NHS can both result from a more service user-centred approach," while the BSR itself has released a "commissioning toolkit" for providers "to help rheumatology professionals develop their knowledge and skills to design effective services and make the most of commissioning opportunities".[198]

156. In other cases the support available for commissioners appears patchy or non-existent. The Royal College of Physicians of Edinburgh, for example, recommended that while CCGs were "in their infancy" there should be strong primary and secondary clinician involvement in commissioning decisions at area and CCG level and the availability of "significant resources" to facilitate the development of integrated services for long-term conditions care.[199] The Anti-Coagulation Self-Monitoring Alliance (ACSMA) proposed a number of practical measures to support commissioners, including "identifying the prevalence and incidence of people requiring anticoagulation services in a local health economy; a national patient experience survey of people using anticoagulation services; incentives and payments directed more towards prevention of ill-health; and engaging with patients and service users in service design."[200] We draw from this proposal the inference that such support for commissioners of such services does not presently exist on any significant scale.

157. The DAFNE programme, a collaboration of 75 diabetes services from NHS Trusts and Health Boards across the UK and the Republic of Ireland, believed that commissioners often did not fully understand the difference in treatment needs and education requirements between type 1 and type 2 diabetes, and thought it "counterproductive" to expect commissioners to "reinvent the wheel" when commissioning services for type 1 diabetes when a national programme of support and education—such as that provided by DAFNE—was available.[201]

158. National Voices, the coalition of health and social care charities, reminded the Committee that the Health and Social Care Act 2012 had introduced common duties on NHS England and CCGs to promote the involvement of each patient in decisions related to the prevention, diagnosis, care and treatment of their conditions. They advocated the creation of a coalition of third sector organisations, experts and think tanks "to gather momentum around the House of Care approach and to challenge commissioners to develop and implement it".[202] The Health Foundation told us that in their view commissioners lacked "an understanding of person-centred care and 'how to get it'": some commissioners recognised the role of supported self-management for long-term conditions in reducing pressure on services, but overall commissioners showed a "mixed" understanding of effective self-management support, and some were "unsure" about how to commission it.[203]

159. The British Society for Rheumatology pointed out that practices in the collection of data to inform commissioning and treatment had not evolved to take account of changes in treatment options for rheumatology: for instance, because of advances in medication, patients with rheumatic disease were now largely treated in ambulatory settings rather than in acute wards. BSR considered that commissioners had little to inform their service specifications, and there was insufficient public health epidemiology data on rheumatic conditions—of which there are over 200—to inform Joint Strategic Needs Assessments.[204] Parkinson's UK was concerned that NHS commissioning outcomes frameworks lacked specific indicators and outcomes for neurological conditions, with the possible consequence that commissioners would focus on targets set by NHS England and pay less attention to addressing indicators and outcomes which were cross-cutting and where benefits were more difficult to demonstrate.[205]

160. The Nuffield Trust summarised the outcome of a research project observing commissioning practice in three sites thought to be at the forefront of commissioning best practice—Calderdale, Somerset and the Wirral—from November 2010 to January 2012.[206] The study focused on commissioning for diabetes services in all three sites, and for dementia in Calderdale and the Wirral and stroke in Somerset. The study demonstrated the intensive nature of commissioning work in the implementation and support of change, and indicated a degree of collaborative working between providers and commissioners. Commissioners were observed to shy away from challenging providers and decommissioning services, preferring to consult on service improvements and develop existing relationships. The Trust thought that in the new commissioning environment commissioners might have to make more difficult decisions on the future of services and be prepared to "cut and run" rather than continue consultative processes when they believed local services had to be changed. Commissioning in the new environment was likely to be "a lonely role" if done well, as commissioner proposals for service change would threaten existing professional and provider interests and could prove unpopular in the community. The Trust proposed a comprehensive list of the support services commissioners would need to take on their new role effectively:

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161. The Nuffield Trust also indicated how some local areas had sought to overcome barriers to integration of services. In addition to the North West London Integrated Care Pilot discussed above, a collaboration of NHS organisations serving a population of 215,000 people in Trafford had collaborated to redesign care pathways, share data, identify patients at risk of unplanned hospitalisation and test approaches to implement and evaluate integrated care. In both North West London and Trafford the Trust observed that the drivers for integrated working had arisen locally rather than under central direction: whatever the outcome of the 14 integration pioneers being promoted by the Department of Health and NHS England, other local examples of innovation were bound to emerge in response to funding pressures and should be evaluated and supported.[208]

162. The Trust identified one possible factor which could inhibit moves to commission more coordinated community-based services: the competition and choice regime, the scope for regulatory action and the operation of procurement law could inhibit commissioners in planning service redesign and innovation. They also considered that the burden of proof on commissioners wishing to redesign services would be substantial, as the benefits of any service redesign which theoretically reduced competition and patient choice would have to be demonstrably "significant, quantifiable and evidence-based". The Trust thought this would be a high bar to meet, particularly given the time required for full evaluation of the benefits of large-scale integrated care projects.[209]

CHANGES IN PRIMARY CARE COMMISSIONING: THE PROACTIVE CARE PROGRAMME

163. In April 2014 the Department of Health and NHS England announced changes to the GP contract which potentially presage a broader shift in the way that primary care services delivered through the GP surgery are commissioned. The Proactive Care Programme is intended to provide greater integration and personalisation in the care and support of those over 75 and those with the most complex health and care needs. GPs will be expected to identify at least two per cent of the population on their practice list with complex needs who will benefit the most from more integrated approaches to the management of their care.[210]

164. The Department of Health expects over 800,000 people to be eligible for the programme. Those enrolled on the programme by their GP practice are promised the following:

· A personalised care and support plan

· A named GP who will oversee the care and support provided and be accountable for it

· A care coordinator who will provide advice on the planning and provision of health and care services

· Telephone consultations with the GP surgery

· Follow-up care after any discharge from hospital treatment

165. The programme depends on substantial multidisciplinary working, engaging community nurses, community pharmacy, allied health professionals, social workers care assistants, volunteers and others to deliver care. The impact of the programme is to be measured and evaluated locally and nationally, with the aim of providing similarly personalised care planning services through general practice to more of the population.

Our view

166. To be effective and sustainable, any reshaping and integration of services for people with long-term conditions must be designed and implemented at local level with the participation and support of leaders of the local health and care systems and active collaboration with the local Health and Wellbeing Board. Models promulgated from the centre are unlikely to work without substantial local adaptation and acceptance.

167. Support and guidance for those commissioning services for long-term conditions appears to be unevenly distributed. Charities and other third sector organisations supporting those with some of the more common conditions or groups of conditions can provide substantial guidance and advice to commissioners on how to plan the provision of services for those with long-term conditions in the local area: but this advice and support is not uniform across all conditions. The NICE quality standards which should inform commissioning decisions are welcome, where they exist, but the provision of such standards is not yet comprehensive. We recommend that NHS England review the condition-specific guidance, quality standards and support available to commissioners from the NHS, from NICE and from third parties with a view to identifying and filling gaps in the support available to commissioners.

168. Guidance from the Department of Health and NHS England will be vital in assisting commissioners to shape the change in services for long-term conditions, but the centre must not prescribe solutions which local health economies are better placed to determine. The contribution of each Health and Wellbeing Board to the determination of commissioning priorities for long-term conditions across each local area will be significant: Boards have a vital contribution to make to the development of the broadest appropriate range of services across the area they serve, taking into account the demand for patient choice. Similarly, commissioners must be flexible and innovative in identifying the providers to deliver the mix of services which will best achieve the objectives for management of long-term conditions in their area.

169. We recommend that commissioners should engage providers and the public as fully as possible in discussions about objectives for health and wellbeing outcomes in their local area and how they might be best be achieved. Commissioners should also explicitly relate payment to outcomes achieved. Local Healthwatch organisations have a role to play in examining how commissioning priorities have been delivered.

A payment system which supports effective commissioning for outcomes

170. Underpinning all commissioning decisions in the NHS is a payment system which governs how funding flows from commissioners to providers of NHS care. The design of this system is of course hugely influential in determining how all healthcare is funded and provided across the NHS, and is consequently key to any redesign of NHS systems to increase effective management of long-term conditions. As we pointed out in our report on our 2012 accountability hearing with Monitor, "The setting of the tariff [for NHS payments] is of great significance to the NHS because of its implications both for short term cash flows in the system, and for longer term incentives for service design. [...] The long-term framework of the tariff will have an immediate effect on service design and the integration of service provision."[211]

ISSUES WITH THE PRESENT SYSTEM

171. Several witnesses identified the prevalence of the present Payment by Results (PbR) tariff for acute care as a major barrier to the commissioning and development of new approaches to the treatment of long-term conditions integrated around treatment of the person. We have ourselves argued that the current tariff arrangements often create perverse incentives for providers and inhibit necessary service change.[212] Dr Nigel Mathers of the Royal College of General Practitioners told us that that reform of PbR was urgently required to incentivise the management and treatment of long-term conditions outside acute care.[213] The NHS Confederation suggested that the NHS should be developing payment systems that incentivised prevention, early intervention, early supported discharge and more integrated working.[214]

172. Professor Alan Maynard, speaking from experience as lay chair of a clinical commissioning group, doubted whether, under present structures, any progress could be made in reducing the number of long-term condition service users treated in acute settings while the tariff continued to benefit hospitals treating patients with long-term conditions:

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173. Martin McShane, of NHS England, recognised the need to establish a new and comprehensive tariff structure for the management of long-term conditions care:

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The Minister of State told us that "the overwhelming need to change from a system that incentivises activity is clear to everyone."[217]

174. We observe that the development of the "new and comprehensive tariff" envisaged by NHS England will need to take multiple factors into account: a comprehensive model will, for example, need to facilitate shifts in the balance of investment in services, including decommissioning services no longer considered appropriate, while also providing funding for local authority and other functions as well as NHS expenditure.

DEVELOPING A YEAR OF CARE TARIFF

175. The Department of Health's QIPP (Quality, Innovation, Productivity and Prevention) programme, which was established to drive forward quality improvements in NHS care at the same time as making the efficiency savings required by the Nicholson Challenge, included a workstream designed to support local implementation of the Year of Care Funding Model for people with long-term conditions.[218] The funding model published by the Department described a potential new way of funding care for long-term conditions, developed to support health and social care providers to integrate care "in a more successful and sustainable way by better aligning the funding flows and incentives with peoples' needs."[219]

176. Following the closure of the Department of Health's QIPP workstreams in March 2013 and their transfer to NHS England, the programme has been taken up under the umbrella of the National Collaboration for Integrated Care and Support. The model under test is an annual risk-adjusted capitation budget based on levels of need. NHS England now believes that this model has the potential to change the payment system for up to 20 to 25% of the total health and social care budget in England, while providing better incentives to providers to improve the efficiency and effectiveness of services for patients.[220] Seven 'early implementer' sites, comprising commissioners and providers, have been working since July 2012 towards implementation of the payment model: "shadow-testing" of the Year of Care currency is expected in 2014/15, with full implementation in 2015/16.[221]

177. Martin McShane, of NHS England, told us that the programme was "discovering some quite exciting information."[222] According to NHS England the achievements of the programme to date include the development of a whole-population analysis approach which can support the development of a national funding framework on the Year of Care model, guidance on collecting the evidence required to demonstrate the effectiveness of earlier discharges from acute care, and the provision of an initial estimate of local per-patient tariffs which might be applied to reimburse providers depending on the health and social care needs of the population cohort addressed. NHS England envisages eventually applying the Year of Care funding model to other groups of service users who receive services delivered through more than one provider.

178. The development of a funding model which supports a 'year of care' approach to payment for the treatment of long-term conditions, rather than an approach to funding based on episodes of care, is welcome. We look to NHS England and the Department of Health to collaborate with Monitor in refining, developing and implementing this approach to funding for long-term conditions, based on an evaluation of the experience of the model in the early implementer sites.

LONG-TERM REFORM OF NHS PAYMENT SYSTEMS

179. The Health and Social Care Act 2012 gives NHS England and Monitor joint responsibility for the payment system for NHS funded care, starting with the financial year 2014/15. In May 2013 both organisations issued a joint discussion paper examining the future of the NHS payment system.[223] They indicated that for 2014/15 the list for nationally-mandated services and their prices—the National Tariff—would remain very close to the tariff agreed for 2013/14, since both commissioners and providers required a payment system to be predictable: some local experimentation would be authorised in order to support redesign of services and to develop a programme for research and development.[224] The formal consultation notice on the 2014/15 tariff was issued in October 2013, and the tariff itself was issued in December 2013.[225] Consultation on the design of the 2015/16 tariff began in February 2014.[226]

180. NHS England and Monitor have indicated their plan to move towards "a single coherent system governing the payment of NHS services".[227] The objective they have jointly set is to design an "overarching payment system" which will enable prices to be set at a national level and varied at local level, and which will "be appropriate for all aspects of health care".[228] They indicate that a review of the operation of the present Payment by Results (PbR) system is necessary: although PbR had supported provider choice and had encouraged hospitals to keep down unit costs, evidence from commissioners and providers, supported by a number of recent reports, had indicated that the present system "does not always promote the best service design for patients".[229] NHS England and Monitor note that "there are few types of care in which paying for activities is sufficient to encourage the best patient outcomes", and that a new payment system could be used to promote better integration of coordinated person-centred care both within the health sector and across health and social care.[230] A payment system with incentives based on outcomes, rather than processes, would evidently influence the behaviour of providers and commissioners alike:

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181. The Minister of State suggested that the process of tariff reform would be facilitated and encouraged by imaginative use of existing flexibilities in the tariff system, especially by the integrated care pioneers:

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Dr McShane described the encouragement to experiment, taken together with the guidance from NHS England to CCGs on planning services for the period to 2018/19, as "a tipping point" for tariff change.[233]

182. In our report on the 2013 accountability hearing with Monitor, we repeated our view that Monitor should attach a higher priority to its work on tariff reform, and further recommended that Monitor and NHS England "should initiate a formal joint process for a prioritised review of the NHS tariff arrangements with the objective of identifying and eliminating perverse incentives and introducing new tariff structures which incentivise necessary service change."[234]

183. Monitor's proposed linkage of payment systems to outcomes, rather than processes, will be highly significant if implemented. Mechanisms designed to promote a different balance of services and care will, for example, have to take into account the funding of links between health care, social care, public health, housing, education and employment. This will require a more joined up approach to the management of long-term conditions within government than presently appears to be the case.

184. Monitor has indicated that a final version of the joint long-term strategy on reform of the payment system will be published in the summer of 2014. We recommend that this strategy explicitly include processes to identify and eliminate perverse incentives in the present payment structure and to develop systems which incentivise models of care centred upon all the needs of the service user. We further recommend that Monitor and NHS England evaluate the results of any tariff flexibilities used in the 14 integration pioneer sites, as well as the general flexibilities introduced in the 2014/15 tariff, and that the interim and final findings of the evaluation should be published.[235]

THE 2014/15 TARIFF AND PARITY OF ESTEEM FOR MENTAL HEALTH SERVICES

185. We note that the guidance to commissioners on the application of the 2014/15 tariff indicates that they should apply a 1.8% reduction in payments for non-acute providers and a 1.5% reduction for acute providers. The disparity between the reductions in payment has caused considerable concern, particularly in view of its likely effect on services for those with long-term conditions which are provided through mental health trusts: concerns have been raised with the Committee in the course of its inquiry into children's and adolescent mental health services and CAHMS. The Minister of State has indicated that he considers the decision by NHS England to cut the tariff for mental health and community providers in a different way from acute providers to be "flawed", and we agree.[236] The Minister has said that there is scope for CCGs and NHS England commissioners to agree with providers "to vary prices at a local level where there is a specific and legitimate reason to do so",[237] and has stated that

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186. We find it difficult to understand how parity of esteem between physical and mental health services can be established, let alone maintained, when Monitor and NHS England have introduced a pricing structure for 2014/15 which has the explicit effect of reducing expenditure for mental health services at a greater rate than expenditure on acute services to treat physical conditions. We agree with the Minister of State that the differential pricing structure is flawed: in our view, it risks a disproportionate reduction in funding to mental health services. Monitor and NHS England must set out in their response to this report what steps they plan to take to support parity of esteem, both through the present tariff system and their proposals for tariff reform.

The effects of system change

187. Many of the arguments made to us advocating a change in management of long-term conditions in the health and care system have suggested that the provision of more personalised and integrated models of care outside the acute sector represents a "win-win" outcome: a move away from an unsustainable treatment model leads not only to better outcomes for patients but also a more effective use of public money in the NHS and in social care.

188. It is nevertheless worth reflecting on some of the implications of the substantial changes to the present model of provision which have been mooted. The Minister of State indicated that the ambition of achieving integrated health and care services by 2017 had been given "quite a turbo charge" by the introduction of the Better Care Fund and the initial pooling of health and social care budgets which the fund promoted: as a consequence "by 2015 the whole country will be starting to see a significant change. It does not all happen overnight, but there will be significant changes happening by then."[239]

The scale and pace of change

189. Dr Sue Roberts suggested that the delivery system for long-term condition management associated with the House of Care model would deliver "a tailored, personalised package of care and support for each of the 15 million people with one or more LTCs."[240] This is a laudable objective for the provision of better care, but it seems improbable to us, on the evidence we have seen, that the prerequisites for the wholesale move to this model—sufficient health professionals trained in care planning and person-centred condition management, a tariff system which prices and allocates resource effectively, and the infrastructure in primary and community care to support an effective care planning approach—are yet available in any NHS England area or region, let alone nationally.

190. CCG plans for commissioning services the five years to 2018/19, which were due to be submitted to NHS England by June 2014, may indicate the extent to which CCGs have foreseen demand for care planning and have begun to commission community services to support those with long-term conditions. But it is only at the point at which NHS England assesses and collates the CCG plans that the scale of the "significant" change predicted by the Minister, and the likely pace of change, will become apparent.

Will the change reduce costs?

191. As we have discussed above, there is evidence for cost savings from the redesign of services for people with long-term conditions in areas where such approaches have been trialled, though the robustness of some of the evidence for cost-effectiveness has been challenged and cost-effectiveness gains from large-scale reorganisations of services can by no means be guaranteed.

192. Funding for the implementation costs of some pilots have been found from anticipated efficiencies elsewhere: we referred above to the allocation of £7 million to the North West London Integrated Care Pilot from commissioner funding which would otherwise have been spent on payments for readmissions to acute providers under the marginal tariff. Clinical commissioning groups are required to hold back 2% of their allocation each year for non-recurrent expenditure, and the Department of Health has indicated that such funds could be used on changes in service mix and the redesign of services.

193. There is nevertheless no guarantee that changes to service design will in the short term be cost-neutral or even result in savings. Redesigning services should not be done on the cheap, but in an era of little or no growth in the health and care budget, expenditure on service redesign is likely in the short term to have to be met by spending reductions or efficiencies elsewhere.

The effect on the acute sector

194. Care planning for long-term conditions management in primary and community care is intended to have the effect of reducing the number of unplanned admissions to acute care services, which by common consent are recognised to be expensive, thereby freeing resource in the acute sector and reducing overall expenditure on long-term conditions. It follows that any substantial changes to the service mix which reduce the activity and the income of district general hospitals generated from treating inpatient and outpatient cases with long-term conditions is bound to have an effect on the acute sector. We note that in the more general context of integrating health and care services, one of the six conditions established for access to the Better Care Fund is "agreement on the consequential impact of changes in the acute sector": local areas are required to identify what the impact of integrating services will be on each provider, and will be required to assure NHS England that there has been engagement with patients, service users and the public on such changes, as well as "plans for political buy-in".

195. Put bluntly, a transfer of services for long-term conditions from acute to community and primary care may well under existing tariff arrangements lead to a substantial drop in provider income. While providers may be able to mitigate the effects of reduced tariff income by reducing the services provided for which there is less demand, the effect of such reductions may well lead to a reassessment of the services offered and consequent pressure to reconfigure acute providers. Merely shrinking a hospital's services in line with reduced demand is in itself unlikely to guarantee the sustainability of the provider: fixed overheads, such as minimum staff and equipment costs and (in some cases) ongoing payments for the construction of new facilities limit a provider's room for manoeuvre.

196. We asked the Minister whether the Department had made any estimate of the number of beds which might be released from the acute sector following any large-scale transition of long-term conditions care to the primary and community sectors. While he had not seen any estimate which may have been made, he was clear that the drivers behind the integration of services should lead to changes in acute provider capacity:

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197. In our recent report on Public expenditure on health and social care we concluded that "advocating service integration without recognising that the consequence of integration is reconfiguration of acute services is simply dishonest", a conclusion which we are happy to repeat here. We observed that the argument for reconfiguration, leading to reduced emphasis on acute services, was supported by considerations of clinical quality as well as economic pressures, and noted that the present health and care system placed insufficient emphasis on identifying early symptoms and supporting normal life, with the result that it provided reactive acute care to patients whose condition should never have been allowed to become acute. The benefit of including Health and Wellbeing Boards in the commissioning decisions about health and care, with a single overview for a given community, should be to engage the local professional and lay communities in a greater understanding of the care quality issues which underlie the case for service reconfiguration, as well as the economic issues involved.[243]

198. We note with approval that a requirement of participation in the Better Care Fund is for local NHS areas to engage with patients, service users and the public on proposals for new integrated services and the consequences for acute service provision. Such engagement should be frank and comprehensive and should make the case for improvements in clinical outcomes and care quality.

199. Without an agreed package for change, and a corresponding commitment to implementation, any large-scale attempt to vary the mix of services for people with long-term conditions is unlikely to succeed. We recommend that NHS England, as part of its five-year planning round, undertakes modelling of the effect of commissioner plans on the acute sector by 2018/19. The likely scenarios for each NHS England area should be referred to the relevant Health and Wellbeing Boards for scrutiny and debate.

142 Q2 Back

143 Ev 75 Back

144 Ev 127, para 2.1 Back

145 Ev 75, para 4; Ev 74 Back

146 Ev 75, para 11 Back

147 The Mandate, p. 13 Back

148 Ev 128, para 2.1 Back

149 The most frequently used subset of ambulatory care-sensitive conditions used in the NHS in England contains 19 conditions, divided into three categories thus: Vaccine preventable: influenza and pneumonia; other vaccine preventable conditions; Chronic: asthma; congestive heart failure; diabetes complications; chronic obstructive pulmonary disease; angina; iron-deficiency anaemia; hypertension; nutritional deficiencies; Acute: dehydration and gastroenteritis; pyelonephritis; perforated or bleeding ulcer; cellulitis; pelvic inflammatory disease; ear, nose and throat infections; dental conditions; convulsions and epilepsy; gangrene. Tian et al, Emergency hospital admissions for ambulatory care sensitive conditions: identifying the potential for reductions, The King's Fund, April 2012, citing Purdy et al, "Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians", Public Health, vol. 123, issue 2, pp 169-173, February 2009. Back

150 Ev 128, para 2.3 Back

151 Ibid, para 2.5 Back

152 Ibid., para 2.6 Back

153 Tian et al,, op. cit., p.1 Back