The Scottish Government

« Previous | Contents | Next »

Listen

12 CHAPTER TWELVE CARE BASED ON COLLABORATION AND INTEGRATION

01 The models of care we describe in this report are based on collaboration and integration. That is an explicit policy direction on our part. We asked Donald Light, Professor of Comparative Health Care Systems at the University of Medicine and Dentistry of New Jersey, for his observations on integration. His insight is interesting. He reported:

"The complexities and understandable divisions of modern medicine have led to a growing interest in integration, or at least greater co-ordination or collaboration, in part because many serious health problems in one organ system have consequences for others and for the patient as a whole. A patient-centred focus also has market and political appeal, so that integration has become an end in itself. It has become a political and organisational movement. But what evidence exists that various forms of integration lead to better clinical outcomes? This would seem to be the "bottom line," though integration has other benefits such as reducing administrative barriers, inducing valuable co-ordination among diverse service providers, and reducing steps, hand-offs and costs, even if outcomes are not measurably better.

Five dimensions of integration have been identified:

1. Administrative: co-ordination or consolidation of administrative functions and planning

2. Organisational: horizontal and vertical networks, joint projects, mergers

3. Funding: shared budgets, incentives, disincentives

4. Service delivery: team-based services, integrated measures of quality and outcomes

5. Clinical: shared knowledge and models of diagnosis, language, practices, standards, measures, and feedback.

Inherent tensions challenge integration efforts and other, related goals. Any one kind of integration can lead to new kinds of divisions or barriers at other levels. Hospitals, for example, have long prevailed in part because they bring together in one place a large number of specialty services and equipment - a one-stop shop for the seriously ill and all the specialties that might be pertinent to a given case. Yet the hospital is considered by many now as the textbook case of fragmented care, and the hospital-community division as the principal obstacle to integrated care.

Decentralisation and devolution as policies aim to integrate care close to patients; yet they are fraught with the dangers of localism, the loss of integrated regional services, and barriers to higher quality services. The models of integrated care, such as the Mayo Clinic in the United States, or the Kaiser Permanente health care system for several million people, involve highly coordinated and centralised standards, information systems, budgeting, and planning. In short, the contradictions between decentralisation or community-based services and integrated services need serious and continuing discussion."

02 Thus integration while remaining a desirable outcome in the interests of delivering seamless services to patients is not without its own problems and contradictions. The bottom line is to develop mechanisms for the planning and delivery of services which are not handicapped and distorted by traditional and inappropriate organisational divides.

03 Within health care in Scotland, the policy environment has been moving steadily in a direction aimed at fostering integration at an operational level. The abolition of Primary and Acute Trusts and their subsumption into unified NHS Boards; the development of Community Health Partnerships and the fostering of Managed Clinical Networks have all been aimed at removing organisational barriers between health care sectors and fostering linkages between them. The organisational underpinnings are increasingly in place and yet there is a sense that the seamless, co-ordinated care at the patient level which integration is meant to foster has yet to happen.

04 Within health care the major fault line which has stood in the way of an integrated system of care is the division between primary and secondary care. In particular this division stands in the way of developing integrated systems of care at a local level.

05 An analysis of models of integrated health care in Scotland pointed out that:

"the traditional hierarchy of primary, secondary and tertiary care fails to acknowledge the potential to do more than ever before close to or in the patient's own home. The absence of locally integrated primary and social care inhibits the realisation of this potential and can contribute to the spectacle of hospitals under pressure, unable to admit or discharge patients fast enough to keep pace with demand"
(Woods, 2001)

06 As implied here, the lack of alignment between practitioners in primary and secondary care may well have been a major factor underlying recent rises in emergency medical admissions especially among older people.

07 The general direction of travel in the health service whereby services involving complex procedures and highly specialist skills are likely to become more concentrated and all other services will be devolved to the local level ('as local as possible, as specialised as necessary') means that the traditional rigid demarcation between primary and secondary care will become increasingly obstructive and anachronistic.

08 If specialist services are increasingly concentrated into centres of excellence, local systems of care will need to develop new integrated models. A local example is shown in Box 12.1 (below).

09 It is perhaps no coincidence that these proposals were only developed in a situation of potential crisis where the impending lack of sustainability of services under existing models of care came face to face with public insistence that services should be maintained at the local level.

10 The wider challenge is to make this sort of change happen throughout Scotland - not as a response to impending crisis but as the key to better patient care.

11 It is an irony of the stress on integration as the way forward in Scotland, that this model of
care - reliant as it is on consensus and collaboration - may lack the kind of levers for change or incentive structures necessary to drive it forward.

12 There is no instant solution to delivering integrated care. It will take consistent and continued efforts from everyone involved with the NHS in Scotland including policy makers, managers and professionals and it is unlikely to happen overnight.

13 Denmark has an integrated yet decentralised system of health and social care. It has been pointed out that this is the product of twenty years of consistent policy making at a national level (Stuart and Weinrich, 2001).

14 Building on the message at a national level there is a need for sustained and consistent use of a range of levers for change. These would include:

• professional engagement and buy-in
• leadership at all levels (national, regional, local)
• development of new roles and clinical specialisms ( e.g. specialist generalists)
• clear and consistent accountability and performance management framework
• incentives wherever possible ( e.g. built in to contracts)
• national support and expertise e.g. for redesign
• resources for innovation and implementation.

15 Integrated services may take on something of the nature of the Holy Grail and yet they are nothing more than the means to an end. Too often the patient journey through the NHS is time wasting, frustrating and illogical. Its shape is determined by outdated organisational structures and procedures rather than the needs of the patient. What integration needs to deliver is a patient journey which makes the organisational divisions in the NHS invisible to the patient.

Mechanisms for Collaboration: Regional Planning and Managed Clinical Networks.

16 In this section we give consideration to two further mechanisms for achieving greater integration and collaboration in planning and delivery: Regional Planning Groups and Managed Clinical Networks. Later in the Chapter, we will return to the topic of Community Health Partnerships whose central role in shifting the balance of care was discussed in Chapter 4.

17 Regional Planning Groups.NHS Boards have long standing statutory responsibilities to obtain the health care and treatment required for the residents of the Board area. The new duty of
co-operation contained in the National Health Service Reform (Scotland) Act 2004 requires Boards to work across current geographical boundaries. Health Department Letter ( HDL) (2004) 46 of November 2004 set out the Scottish Executive's expectations about how Boards would respond to the new duty through a greater emphasis on regional planning. It was envisaged that regional planning would be necessary in order to:

• implement national priorities for NHS Scotland;
• examine the sustainability of services;
• improve patient pathways of care and enable more appropriate access to services;
• allow local access to services previously available only in specialist centres where providing that local access will improve the clinical outcomes;
• assess the regional implications of NHS Board Service Plans, including the case for migrating more complex activity to tertiary centres;
• develop capacity in workforce planning and development which support changing models of care;
• co-ordinate campaigns on health improvement or lifestyle issues in order to maximise benefits;
• review the provision of emergency healthcare services at a regional level;
• commit to develop public involvement strategies at a regional level;
• promote service redesign through a sponsoring or supervisory role in relation to appropriate MCNs;
• tackle issues that are common to all Boards.

18 Effective Regional Planning is essential to support the delivery of a modern, integrated and sustainable NHS. Ministers have been clear that they expect to see a step-change in the development of regional approaches to service improvement. The three Regional Planning Groups are required to ensure a more systematic approach to planning and delivering those health care services which are best provided to the people of Scotland at population levels above that of the individual NHS Board. Accordingly, Regional Planning requires NHS Boards
to recognise the benefits of sharing their responsibilities and resources in respect of such regional services.

19 In subsequent discussion with NHS Boards, a number of principles were developed. Too often in the past, regional planning has been used as a fall-back - occasionally even as an approach of last resort. The idea behind the principles is to establish some ground-rules that will determine when regional planning will become the default position - rather than the fallback:

20 Our Report has a number of proposals that give flesh to the bones of the principles. For example, in unscheduled care, we recommend that those facilities providing emergency admission should be planned regionally. In elective care, we recommend that the planning regions need to come together to plan and deliver the streaming of elective care (away from unscheduled care) and the diagnostic and treatment configuration required to support such an approach. We also suggest a regional approach to referral management giving patients a range of choices about how, where and when their referral is taken forward.

21 This will require a more systematic and better resourced approach to regional planning. Taking account of how little dedicated resource has gone into regional planning, the three Regional Planning Groups (North; West; and South East and Tayside) have achieved a great deal. They are making progress with planning specialised services such as cancer (in co-operation with the cancer networks), paediatric services and specialised mental health services. All three are also embarked on reviews of acute service provision and scoping work around maternity services.

22 This report calls for a step change in that activity. The regional Groups will require additional dedicated resource if they are to take forward the challenging agenda described above.

23 Managed Clinical Networks. It will be clear from the earlier chapters of the report that Managed Clinical Networks ( MCNs) are seen as the way of implementing many of the recommendations from the individual Action Teams. The concept of MCNs was formalised by the report of the Acute Services Review (Scottish Office, 1998), as a way of building on the collaborative working which was already common amongst clinicians. The key difference which MCNs made was to insist on giving patients a strong voice in the way the service is delivered (see the core principles of MCN development, as set out in HDL(2002)69).

24 A wide range of MCNs is now in existence or under development at NHS Board, regional and national level, with demonstrable improvements in service delivery to their credit. This approach should continue, since MCNs have a number of functions to perform. They should continue to be the engine room of quality and clinical improvement and re-design. There is also a continuing need for the integration of services which MCNs bring about, not just within the NHS but across the boundary between the NHS and local authority services. The Networks providing this wider integration are generally referred to as 'Managed Care Networks'. In the more rural parts of the country, MCNs also have a particular role in helping to make sure services are fully sustainable, as well as providing a combination of local access and ready referral to specialist advice when needed.

25 Experience to date suggests there are a number of key factors which need to underpin all MCN development in the future:

• providing MCNs with their own commissioning budgets may risk increasing bureaucracy by creating mini health economies. MCNs therefore need to be fully integrated with NHS Boards' functions. One way of achieving this is to make sure that MCNs have access to collaborative contracts, as these are developed by CHPS, thereby helping to target resources to the developments to which the MCNs give priority. Performance management arrangements also need to take more explicit account of the role of the MCNs. NHS Boards should recognise the MCNs' work, and should be held to account if they fail to do so. Management in Operating Divisions needs to participate in and assist the aims of MCNs, and should be challenged if they do not do so. There needs, however, to be clarification of roles, responsibilities and accountability between MCNs and Boards or Regional Planning Groups.
• there needs to be a more systematic approach to the development of MCNs. The process has been organic so far. There therefore needs to be greater clarity about the tests to determine whether the creation of an MCN is the most appropriate response to a particular concern. One of the most significant of these tests would be the extent to which the development of an MCN would promote patient choice, as opposed to professional opinion. Boards need to accept a role in stimulating MCNs in [service/specialty] areas where there is no clinical champion but it is clear that patients would benefit from an MCN approach.
• the work on MCNs needs to take account of the advent of Community Health Partnerships, which are about better supporting people at home, a reduction in avoidable hospital admissions, enabling greater access to diagnostic services and improved discharge planning and rehabilitation. MCNs are involved in each of these aspects of service delivery, and this should form the basis for the links which need to be developed between MCNs and CHPs;
• a strong IT base provides an essential stepping stone for MCN development, and the sharing of information helps to unite patients and health professionals. The IT needs of MCNs must therefore be an essential element in their resourcing [by NHS Boards or Regional Planning Groups], on the grounds that what cannot be measured cannot be improved. The collection of audit data is a fundamental feature of MCN activity.
• the role of Lead Clinicians needs to be fully recognised, especially in terms of the allocation of time needed to do the job properly. This would be assisted by the introduction of a process of appraisal of the performance of Lead Clinicians, which should probably be undertaken by the relevant NHS Board. More generally, the performance of health professionals within MCNs should form part of the overall assessment of their performance.

26 We think that the MCN model should be expanded, learning the lessons from those already accredited. In expanding the model, it will be important to recognise the implications of the trends identified earlier in this report: we will need to provide ongoing care to patients with a combination of conditions. The MCN of the future needs to be able to deal with the whole patient and not just a single disease.

27 These points should be incorporated in a new Health Department Letter on MCNs, which the Department should issue as soon as possible after the publication of this report. This will help implement those of our recommendations which depend on an MCN approach, as well as sending a clear signal that MCNs continue for the foreseeable future to be an essential part of the Scottish approach to service development and integration.

Health care as part of a wider system

28 The Health Care system on its own cannot deliver the aspiration for more local care, more effective rehabilitation and discharge from hospital, better assessment and avoidance of emergency admission. Nor can it deliver improved quality of life, reduction in health inequalities and health improvement without the wider network of public services, the voluntary sector and service providers.

29 The most significant interface is with local authorities, and particularly with social work services.

30 Housing services also have an important part to play, since the ready availability of suitable accommodation, either purpose-built or adapted, it is critical to the support of children and adults of all ages in their own homes.

31 In relation to children, integration has mainly focused on how social work, health and education work together.

32 Services must ensure there is a steady flow within and across systems to maintain efficiency and reduce duplication. To achieve this we must clearly understand the whole system, isolate the key areas where flow is compromised and re-design systems where necessary.

33 The joint working agenda between health and social care for adults is usually referred to as "Joint Future" following the Scottish Executive report of the same name in 2000.

34 Joint working is now embedded in the way health and councils work together. For example, 32 joint partnerships were set up in 2002, reflecting the 32 local authority areas, and national guidance for health and local authorities on developing joint services, called "Better Outcomes for Older People" has been developed. It will now drive the mainstreaming of joint services, firstly for older people and then all care groups.

35 The scope of Joint Future activity is wide-ranging, taking account of community care services, free personal care, single shared assessment, the delivery of equipment and adaptations and other areas where there is the potential to add value through joint, aligned or pooled services or resources.

36 There is also a national high level partnership between Ministers and CoSLA which has recently set out four National Outcomes that local partners should achieve through joint working:

• Supporting more people at home, as an alternative to residential and nursing care, through local agreed joint service developments such as: Increasing the range and use of domiciliary services e.g. Care and Repair, equipment and adaptations (including SMART technology) and intensive home care packages.
• Assisting people to lead independent lives through reducing inappropriate hospital admissions, reducing time spent inappropriately in hospital and enabling supported and faster discharges from hospital through service developments such as: providing more "half-way house" services, e.g. step up, step down, rehabilitative services etc; more rapid response services.
• Ensuring people receive an improved quality of care through faster access to services and better quality services, through developments such as: single shared assessment; self assessment; quicker integrated care packages being delivered; greater satisfaction of service users and carers; the range and quality of their care package and the way in which staff from different organisations work together to assist them; one stop access to jointly delivered care packages.
• Better involvement and support of carers through developments such as: carers' partnerships and carers' strategies; better quality of services for carers, fit for the purpose and fit for their future; increasing the range and flexibility of carers' services; clear signposting and promotion of the range of care packages and support available to individuals and groups.

37 In turn, all local partnerships must set annual Local Improvement Targets, for 2005-06, for these National Outcomes. These targets focus on 7 core areas such as more intensive home care, more and faster equipment and adaptations services and better support for carers.

38 A joint performance assessment framework measures how well the partnerships are implementing both organisational arrangements such as joint committees and - more importantly - delivering better joint services for people. A Joint Improvement Team has been set up to assist partnerships where there are difficulties.

39 At the strategic level, the key mechanism for driving integration and health improvement is the Community Planning Partnership.

40 These Partnerships, based on local authority boundaries, bring together representatives of major stakeholders within that geographical boundary. This includes not only agencies such as the local authority, the health service, the Police, the Fire Service and Scottish Enterprise but also community representatives, the voluntary sector, and business interests.

41 The purpose of Community Planning Partnerships is to deliver co-ordination of local strategies of all key organisations in a local authority area, with full participation of community representatives. For some purposes, the Community Planning Partnership also allocates resources from the Scottish Executive, which are provided for purposes across more than one agency, for example, Better Neighbourhoods Services funding.

42 The Community Planning Partnership is particularly well placed to deliver health improvement outcomes and to develop cross-agency strategies which address health inequalities. There are many good examples of this across Scotland.

43 Joint working and joint services have been given significant impetus by the Joint Future initiative. Good examples of joint services such as rapid response teams for adult people leaving hospital have now been rolled out in almost every partnership in Scotland. This reflects the fact that many people have complex needs - both health and social care - and joint working can mean a quicker and better response to assist individuals.

Community Health Partnerships

44 As we highlighted in the section on care in local settings, Community Health Partnerships ( CHPs) are explicit vehicles for collaboration and the integration of services at a local level. They provide a focus for integration between primary care and specialist services and with social care. To achieve this CHPs will need to link clinical teams; work in partnership with local authorities, the voluntary sector and others to support the improvement of the health of local communities; and most importantly involve the public, patients and carers in decisions concerning the delivery of health and social care for their communities.

45 It is expected that there will be change at the leading edge of service delivery - by developing integrated care and treatment for local people; and providing access to community based services which would otherwise require a trip to hospital.

46 As partnership arrangements with local authorities develop, it is likely that the range of services with joint outcomes and performance management will increase. This trend will require practitioners to consider shared healthcare governance arrangements to support joint working arrangements.

47 A critical aspect of the work of every CHP will be to place the public at the centre of the drive for quality improvement and service design and delivery. Consequently frontline practitioners will need to be geared up to respond to the increasing pressure from the public/patients and carers (often channelled through Public Partnership Forums within each CHP) to improve standards and patient safety.

CHPs: levers for integration

48 Given the importance of their role and the fact that CHPs are in their infancy, it will be important to ensure that they are equipped in terms of vision, aims, objectives, performance, governance and accountability. We recommend that NHSQIS develop a set of CHP quality indicators. This would provide a comprehensive framework, consistent with their contractual obligations, to set out for CHPs, their staff and the public the quality standards they are expected to meet and against which their performance will be assessed. In addition the Scottish Executive, working with NHSQIS should develop a methodology for accrediting CHPs against these standards, possibly based on that used for managed clinical networks.

49 One of the factors which the quality indicators must address is the desired outcome of integration between primary and secondary care. That means that clinical leaders from general practice and from hospitals must be brought together as members of the CHPs to provide direction.

50 One of the outcomes of the accreditation process might be to evaluate the extent to which CHPs are able to take on financial delegation from NHS Boards. We are convinced that such delegation must take place. Budgets for developing integrated care solutions are currently tied up in hospital based services. In Professor Light's work for the National Framework about the obstacles to productive and integrated care, he suggests that budget barriers such as this create "blocked incentives" which are in turn responsible for unnecessary referrals and admissions to hospital, clogged waiting lists, poor discharge etc. and suggests "collaborative contracting" as a possible solution.

51 We were struck that if we can get the collaborating parties working jointly in CHPs, (with delegated budgets within which they could re-invest savings), then we might be able to find shared incentives to deliver integrated care. In the NHS, the key collaborating parties are General Practitioners (as gatekeepers to the system) and Hospital Consultants. Both must be firmly embedded in the CHP structure. But for CHPs to be a success, so too must other clinical leaders.

52 There should be scope too for this collaborative contracting approach to facilitate the more effective use of diagnostic services and for it to dovetail with the referral management approach mentioned earlier in the report. There is also potential for Managed Clinical Networks to put together collaborative bids for operational budgets aimed at improved integration. Over time, the CHP would become responsible for financing from its delegated budget all services provided for its community whether they are community based services or hospital based services. It would be responsible for waiting times and quality.

53 We recommend that as CHPs mature, and meet the quality standards referred to above, that we should pilot this approach in a number of CHPs. It will require clearly agreed outcome targets, tariffs to be set to enable appropriate budget shares to be assigned to the CHP and careful evaluation. But we believe it has the potential to incentivise integrated care.

Integration and collaboration: the pay-off

54 The mechanisms outlined above - Regional Planning Boards, Managed Clinical Networks and Community Health Partnerships - greatly improve the prospects that the NHS in Scotland will in future be able to plan and provide services which are integrated and collaborative and meet the needs of the patient for a seamless service. However there may still be some nervousness about whether it is all worth the effort. Is an integrated NHS worth pursuing or is it a holy grail that may be sought but never found?

55 As mentioned above, we asked Professor Donald Light to advise us on whether there was evidence that service change aimed at integration of care had delivered a successful outcome in terms of patient care, quality of care and cost effectiveness. Professor Light reported to us that in his view, "the most successful integration of a large public health care system is the Veterans Health Administration ( VHA) in the United States".

56 The VHA case study referred to below suggests that the search for integration might just be worth all the effort. The supporting material is drawn from two sources - an article in the American Journal of Managed Care by the VHA's Under Secretary, Jonathan Perlin and others (Perlin et al., 2004) and an article by Carol Ashton and others in the New England Journal of Medicine (Ashton et al, 2003).

57 The Veterans Health Administration is the United States' largest integrated health system. Once disparaged as a bureaucracy providing mediocre care, it has reinvented itself over the last decade through a policy shift mandating structural and organisational change, rationalisation of resource allocation, explicit measurement and accountability for quality and value, and development of an information infrastructure supporting the needs of patients, clinicians and managers. Today the VHA is recognised by independent observers for leadership in clinical informatics and performance improvement: it cares for more patients with proportionally fewer resources, and sets national benchmarks for patient satisfaction and quality of care.

Figure 12.1 Decrease in Hospital Admissions and Increases in Outpatient Visits in the Department of Veterans Affairs from 1995 to 2003.

Source: Perlin et al, 2004

58 The VHA embarked on its transformation in 1995. It had long been organised around its hospitals and subspecialty services with individual hospital level units operating with relative independence from each other. But new developments in medicine had shown that many serious and chronic problems could be treated more effectively and at less cost using a home- and community-based delivery system centred on primary care.

59 Between 1995 and 1999, the transformation established over 300 new community-based outpatient clinics with telephone-linked care to specialists at VHA hospitals. Annual inpatient admissions declined by more than 32%, while ambulatory visits increased by more than 45%. The proportion of outpatient surgeries increased from 35 to 70 percent. Sixty percent of VHA beds were eliminated, while the number of patients treated per year increased by 25%. By 2003, the VHA had 850 community-based outpatient clinics and more than 300 long-term care facilities, domiciliaries and home-care programs. Total beds had been reduced from 92,000 in 1995 to 53,000 in 2003, and hospital admissions from 900,000 to 600,000, while outpatient visits had increased from 26 million to 52 million.

60 The structural transformation of VA was characterised by the creation of 22 geographically defined Vertically Integrated Service Networks ( VISNs). Resources were allocated to the network rather than, as previously, to the individual hospital or facility thus creating financial incentives for co-ordination of care amongst previously competing facilities. The similarity to the unified NHS Board structure in Scotland is striking and the incentives apply here too. Too often, additional resources are used to fund more of the same ways of working. We need more of a zero based approach with incentives to rethink how we deliver services.

61 The reduced hospital use has had no adverse consequences as measured by long term survival rates. Carol Ashton was good enough to come to Scotland to brief us on her analysis of patient outcomes. She found that over the period between 1994 and 1998, when bed day rates fell by 50% and urgent care visits fell by 35%, there was no significant change in survival rates over a range of conditions. (Figure 12.2.)

Figure 12.2:
Hospital Use and Survival among VA Beneficiaries.

Source: Ashton et al, 2003.

62 What are the lessons from this remarkable transformation? The first lesson is to develop a clear, comprehensive vision of where one wants to go and stick to it, in this case a vision of home- and community-based integrated care.

63 A second lesson is to establish an accountability system. All clinical and administrative leaders were put on performance contracts, with bonuses for achieving performance goals. As measures matured, they shifted from inputs to outputs and outcomes. Quality was objectified in terms of outcomes of interest to patients and others in six "value domains": access, technical quality, patient functional status, patient satisfaction, community health, and cost-effectiveness. A Prevention Index, a Chronic Disease Index, and a Palliative Care Index were developed and implemented system-wide. Audits are performed by an independent external contractor under the External Peer Review Program.

Figure 12.3
Outperforming the Private Sector with more challenging patients

Source: Perlin at al., 2004

64 Of particular note is the development internally of a computerised patient record system ( CPRS) that integrates data from ambulatory, inpatient, long-term care, and home care sites and provides a single, graphical interface with all providers and with the patient. Information is organised to support clinical decision making and to be patient-centric. All charts, notes and images are available through the web at all sites. The system is vital for integrating guidelines, prompts, alerts, order-checking, adverse reactions, and also for evaluating system-wide any new drug or procedure.

65 As Figure 12.3 shows, the VHA outperforms the private sector on various measures, despite having less money, sicker and older patients, and more difficult problems of access to overcome.

Cost implications

66 In recommending change, we need to have some degree of certainty that it will be sustainable and affordable. We believe that what we propose meets both criteria. Of course, as with any change programme, there is uncertainty and an absence of fully costed data. We are recommending new ways of delivering services and accordingly there is only limited data about cost effectiveness.

67 We asked Dr Andrew Walker to provide a commentary for us on the economics of our proposals. Dr Walker sounded a note of caution in suggesting that there was limited evidence of costs and benefits for changes of this magnitude and he pointed out that the studies which do exist might not generalise to other settings. He noted for example that the evidence on changes to the emergency care network was patchy.

68 But, on the other hand, he concludes that the shift away from acute care and towards preventative services and management of chronic diseases (which is central to our proposals), can improve the long term health of the population without additional spending, so long as the services involved are carefully selected. And he point out that chronic disease management can be cost effective but is unlikely to be cost saving.

69 Taken in the round, and notwithstanding the shortage of hard data, we expect the changes outlined in this report to be cost neutral for the whole NHS but that they will require more weight to be given to providing care in local communities in allocating the future increases in the health budget.

Summary of recommendations

01 The Scottish Executive should recognise and support three levels of planning:

• National - led by the Scottish Executive, working collaboratively with the three Regional Groups as the usual planning mechanism for highly specialised services that we should only deliver on one or two sites in Scotland.
• Regional - led by the Regional Planning Groups, working collaboratively with Boards as the usual planning mechanism for acute hospital services.
• Local - led by NHS Boards, working collaboratively with CHPs as the usual planning mechanism for delivering integrated care in local communities.

02NHS Boards should reallocate and pool resources to ensure that Regional Planning is formalised with more staff allocated to it and with a clear agenda based on the priorities identified in this report.

03 The Scottish Executive should ensure that the contribution made to regional planning is more formally part of the delivery and accountability requirements for NHS Boards.

04 There should be continued and more systematic development of Managed Clinical Networks as vehicles for service redesign, quality improvement and integration of services.

05 More integrated planning and delivery of health, health improvement and social services should continue to be developed via such vehicles as Joint Future and Community Planning Partnerships.

06 The Scottish Executive should work with NHSQIS to develop a set of Community Health Partnership quality indicators. Integration between primary and secondary care should be one of the outcomes addressed by these indicators.

07CHPs should be the main vehicle for integrating care in local communities. In doing so they should:

• ensure clinical leaders from primary and secondary care are engaged,
• develop co-ordinated data across primary and secondary care,
• work towards accreditation on the basis of standards to be developed by NHSQIS
• develop collaborative budgets across primary and secondary care, linking where appropriate with Managed Clinical Networks.

08 The Scottish Executive should explore options for aligning financial rewards and incentives to contributions to service improvement.

References

Ashton C, Souchek J, Petersen N et al. (2003) Hospital use and survival among Veterans Affairs Beneficiaries. New England Journal of Medicine 2003; 349:1637-46

Perlin J, Kolodner R and Roswell R (2004) The Veterans Health Administration: Quality, Value, Accountability and Information as Transforming Strategies for Patient-centred Care. The American Journal of Managed Care 2004; 10(part 2): 828-836

Scottish Office (1998) The Review of Acute Hospital Services. Edinburgh: The Stationery Office June 1998

Stuart M and Weinrich M (2001) Home is where the help is: Community-based care in Denmark. Journal of Ageing and Social Policy. 12 (4) 2001

Woods K (2001) The development of integrated health care models in Scotland. International Journal of Integrated Care 1:3 June 2001 http://www.ijic.org/index.html

« Previous | Contents | Next »