My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Real integration needs tough, powerful integrators

Filed Under (Contracts, GP Commissioning, Integration) by Paul on 30-05-2012

Over the last few weeks I have been outlining the different mechanics of new elements of reform that will be necessary if commissioners are going to be able to transform health care for NHS patients. A few weeks ago I mentioned the importance of them buying effective packages of self care. Last week I outlined two different approaches to the way in which commissioners contract health care and today I want to outline some of the radical thinking that is taking place about how the provision of integrated care can be developed.

This article first appeared in the HSJ on April 12 this year.

“It seems to me that the more everyone agrees with the policy of integrated care, the further away the reality of integrated practice seems to be? For me it comes with the way in which the argument for integrated care was won last summer.

The government were being battered with accusations of wanting too much competition and a whole raft of people used the importance of the delivery of integrated care as another argument to hit the Government with about competition. For a while you could easily demonstrate your anti-competitive credentials by simply being in favour of integration. For most of that past year competition has meant tough and nasty and integration has meant soft and cuddly.

But the problem is that soft and cuddly never manages the hard conflict that is necessary to bring about real change. Soft and cuddly did not bring down waiting times in the NHS.

This approach has left us with a bit of a conundrum. Across the country the policy of integration wins every argument in the local, regional and national working groups that discuss it. And at the same time as the policy discussion is won, across the country the practice of working in silos keeps winning most of the reality on the ground.

I was working with some people developing integrated mental health services the other day and they worked out that there are about 1000 people who are essential in their locality to developing an integrated service for mental health. They came from about 15 very different professional cultures. For them to really work together will need very serious changes in the way in which they all work. Whilst there will be gains for most patients there will be some form of loss for most of the staff in terms of the professional culture in which they have been successful.

For the NHS I hope there will be a range of different answers to this. But for me one of the answers must be found in the weight and power that the ‘integrator’ has in changing all those silo’d cultures in order to deliver integrated care. My problem is that I don’t think this can be done by a committee of all the different and previously unintegrated providers.

My experience of committees of everyone is that they don’t have the power to change anyone. This is an example of the problem of believing that integration only comes from co-operation.

Other industries that need to bring together a very wide range of cultures and skills to complete a complex project recognise the integrator of the project must have more power than anyone else. If any one of the providers thinks they can simply do what they have always done before, then the interconnectedness of the whole project falls apart.

In these industries there is a prime contractor model.

Within this model the customer or commissioner has a contractual relationship with one organisation to deliver the entire project, in our case the entire patient pathway. It is the task of the prime contractor then to ensure that all of the other specific providers develop services (and cultures within those services) that are fully integrated one with another. Such an integrated culture does not miraculously appear from the current silos, it needs to be created through the hard work of a powerful integrator. And the most powerful integrators are the ones that hold the overall contract and can therefore demand integration as a part of the service.

So where does competition come into this model? We need different – and competing – models of how powerful integrators would work with existing service providers to develop the fully integrated service. Commissioners must contract for a set of health care outcomes from these integrators and help to create a market that will ensure that these different approaches to the prime contractor model compete with each other to find the best way to achieve those outcomes.

No one is saying that the prime contractor model is the only way to create integrated care. But I think I am saying the integrator in any model is going to need some real power to make integration happen.

For further information on the Prime Contractor model go to: http://www.rightcare.nhs.uk/aics/

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