The route map to a better care system, through ICOs and AHSCs

The integrated care organisation (ICO) and the academic health science centre (AHSC) are the structures that will deliver better outcomes within the UK care system. Evidently, the fully formed organisations, mechanisms and markets will not emerge on day one. Rather, a transition will be required. At the start, it will be more managed. At the maturity stage, it is self-sustaining as the demand-driven mechanisms drive on-the-ground adaptability and alignment of the system with need.

Step 1: The journey of a thousand miles begins beneath one’s feet

• Bed blocking
• Poor access to primary care
• The clinical inefficiency of sub-scale units in hospitals l The absence of joined-up care pathways

Unless we can solve these problems, overcoming the detailed constraints to change – such as stand-offs between the NHS and local authorities on who pays once a frail older person leaves hospital – integration will remain a pipe dream.

Step 2: Analysing data and introducing new pathways

The outcome-information exercise begins in earnest in this phase. Population data for cohorts are analysed, patterns identified and conclusions reached through inductive logic. Personalised, integrated care packages and care pathways are introduced for “frequent flyers”: the people who are most frequently attending A&E and being admitted to the acute hospital. These packages and pathways are managed by a case manager, who is responsible for instituting a robust crisis management procedure for the frequent flyers. Care pathways are measured for outcomes.

Step 3: Creating expert commissioners

Existing clinical commissioning groups (CCGs) are too small to be expert commissioners. In step 3, lead CCGs are created by amalgamating existing bodies (incorporating existing, overlapping bodies, such as health and wellbeing boards).

By this time, there will be a growing body of data and evidence on what treatments and interventions work best. The lead CCG will be able to use risk stratification techniques to identify the most high risk/high cost individuals. These people can then benefit from integrated care plans, a case manager, funding agreed against assessments, a single point of crisis contact, and so on.

Step 4: Managing the market and harnessing the power of digital

Lead CCGs start to actively manage the market and begin tendering for cohort management. The lead CCG will also begin to shape the choices that academic health science centres make about which clinical domains they will concentrate on to build national and global merit.

The lead CCG will elevate the paper-based integrated care plan into the first building block of an electronic patient record. This EPR will incorporate all data that currently exists on the individual, regardless of which system it is currently held in (primary care, local authority, hospital etc).

The lead CCG can start experimenting with new funding and charging approaches, such as financial penalties for abuse of the A&E system.

Step 5: Effective electronics

Step 5 is engaged in getting the electronic platforms and records to work effectively. Once electronic patient records are available and there is reliable network connectivity, so the unique DNA profiling of individuals can begin, and links to the research organisations can be made more robust.

Step 6: From illness to wellbeing

In step 6, the work of the ICO on illness can be supplemented by initiatives on wellness, including the encouragement of self-care.

Step 7: The extension of cohort management

By this stage, cohort management has extended to all high risk/cost groups. This stage represents the culmination of background work to repurpose care settings (creating polyclinics and intermediate care centres). It is also the culmination of reshaping and reskilling the workforce so that it has the appropriate blend of skills and disciplines to meet the needs of patients.

Step 8: To risk management

The data on which treatments and interventions are really effective and where the resources need to be spent to have the highest impact will be increasingly available and reliable. On this basis, it will be possible to extend the concept of the ICO so that it is a risk management operation and not just a service management operation.

Step 9: Further erosion of boundaries

In this stage, the ICO extends to cover troubled families. It will take time to integrate health and social care, but eventually it will be possible to extend the concept to include, especially, the criminal justice system. This will have a major impact on individuals and society – and also on the costs of the broader system, including the police, the prisons and the probation services⁴⁶.

Step 10: The virtuous circle

The UK care system is operating as an efficient market in which:

• Expert commissioning interacts with the deployment of high quality outcome information
• The outcome information allows individuals, who will be in possession of personal budgets, to discipline the system
• Services constantly reconfigure around the changing needs of the population, driven by the excellence and innovation that comes from competition
• Risk managed, individualised, whole person care is at the heart of the system

The Boston Consulting Group have said:

“As more and more data about health outcomes becomes transparent… some stakeholders are taking on more of the risk associated with managing whole patient health. Because of the complexity of managing the entire health needs of a broad patient population, this is the most advanced version of competing on outcomes.

“Only players that have reached a high level of data sophistication, and that understand their patient segments well enough to minimize risk and to provide quality outcomes at relatively low cost, will be successful. Organisations that currently come closest to adopting the whole-patient-health approach are the single-provider integrated-delivery systems in the US, such as Kaiser Permanente, Intermountain Healthcare, and the Geisinger Health System.”⁴⁷