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Integrated Care Boards and their system partners are tasked with working collaboratively to deliver four core aims: the Triple Aim duty of improving health and wellbeing, increasing the quality of healthcare services, and making sustainable and efficient use of resources, as well as helping the NHS to support broader social and economic development.
Integrated, system-wide working requires finance teams and procurement advisers to support system leaders in developing more joined-up, sustainable care by engaging much earlier in the commissioning process, building services that prioritise best value outcomes for patients and communities. The potential benefits of this are clear but there are significant challenges to overcome too.
Evaluating value across care pathways
Patients touch health services across a system in multiple ways, from GP services to emergency care, and yet services are traditionally commissioned in silos within primary, secondary and specialised sectors.
There are some instances where care is integrated across these functions, such as the single contract provision for prison health services covering everything from dentistry and primary care through to emergency treatment and mental health support.
Although the circumstances in that case can be more clearly defined, it demonstrates that procuring integrated services at scale can be achieved.
Joint working at system and place level creates opportunities to consider the whole pathway of care and identify opportunities to improve, simplify or adapt each element based on the value it brings.
While it is for clinicians to determine the best approach for their patients, finance specialists can support clinical teams by applying LEAN principles to objectively assess which elements across a pathway add most value and which don’t, potentially releasing efficiency savings while maintaining or improving quality outcomes.
Assessing the full musculoskeletal pathway from initial contact through to surgery, for example, provides an opportunity to assess the value of each step, including whether earlier intervention or different, less invasive treatments early on might delay or remove the need for surgery.
Similarly, early identification of diabetes risk, followed by support with diet and exercise, could reduce the impact of the condition, both on patients and the health service.
A strategic view of savings
One of the challenges, however, is this may mean taking money from one part of the system and putting it into another.
Where does the incentive lie for individual organisations perceived to be missing out? We are still largely working in an environment where organisations are rewarded for outputs, which makes it harder to incentivise doing less, beyond a clinician’s natural inclination to do the best for their patient.
But those incentives do exist.
Reducing the need for hip and knee replacements, for example, means those for whom surgery is the best option could be treated more quickly, bed capacity should improve, and hospitals can move towards operating within their means.
We also need to recognise that while removing part of a pathway that isn’t adding value may free up some resource, that won’t always convert into a financial saving due to other factors.
But there’s still an efficiency to be gained in being able to divert that resource to other initiatives that deliver greater value and in simplifying the treatment pathway.
This can lead to better quality outcomes for patients and efficiency savings for the NHS, if not always in cash terms.
Asking the right questions to support integrated care
Diverse stakeholder engagement is needed to build confidence in this integrated approach.
Increasingly, finance experts are being invited in at the start to help devise a specification and understand the art of the possible based on the outcomes being sought.
Procurement advisers need to be thinking strategically about different procurement options.
System leaders will have a mix of neighbourhood, place-based and system-wide priorities, some of which will apply pan-region or nationwide.
Where can we adopt a systematic review of treatment pathways to robustly review quality and outcomes?
What new services might we need from the market? And where is there value in doing that outside system borders?
How can we work with providers to ensure the market keeps pace with changes in the way services are being delivered, either using our collective buying power to achieve best value, or detailed engagement to identify niche solutions for specialist care?
Creating opportunities for these sorts of questions to be asked as part of a multidisciplinary team will enable finance and procurement experts to add real value to this new way of working.
By bringing finance and procurement expertise into the planning process at an earlier stage, systems will be better placed to achieve the clinical priorities and desired outputs of the Triple Aim.
