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.

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Does the answer to the problem of creating integrated care lie entirely within the NHS?

Filed Under (Health Policy, NHS Providers, Patient Choice, Private Sector, Reform of the NHS) by Paul on 16-06-2011

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Regular readers will have noticed that the relationship between integration and competition is an topic upon which I have posted a couple of times in the last few weeks. In my view all the commentators pointing out the importance of creating integrated care services for the NHS are correct.

The NHS has developed an episodic care service that is appropriate for episodic illness, but is simply unsuited to caring for long term conditions. Add to this the split between primary and secondary care and you have a model of service that is in no way fit to manage the 75% of NHS resource that is spent on long term conditions.

So if everyone is right, developing integrated care is vital for the future. Under the tutelage of the Future Forum over the last 10 days, even the Government have now recognised this reality.

Some commentators – especially the Royal College of GPs and the BMA – claim in making their case for integrated NHS care services that the introduction of competition would contradict a move towards integration. Therefore, they argue, if we want integration we must not introduce more competition.

The only rationale I can find for this argument is that the kind of emotions that working together engenders in peoples’ minds are different from those brought about by working in competition. Given that one is warm and the other fierce they must be in opposition to each other?

But, as so often happens in life, you don’t have to have all of your emotions at the same time. You can sequence these emotions. You can, for instance, have a period of time during which you ask organisers of services to compete in making their case to commissioners for how they will better integrate the services to be provided. Then the commissioners can decide which integrator is best able to deliver those services.

The period of competition creates the conditions for better integration.  .

Last Sunday morning on Andrew Marr’s Politics programme there was an interesting vignette of this debate between Clare Gerada from the Royal College of General Practitioners  and Stephen Dorrell who chairs the House of Commons Health Select Committee.

Both of these people have a deep knowledge of organising the NHS and have recognised the importance of developing integrated care. But their solutions are in competition with each other.

Clare Gerada believes that more competition will unpick the existing integration that has existed in the NHS for the last 65 years. She is therefore against introducing more competition as it would stop people working together.

Stephen Dorrell argued that fragmentation is a part of the history of the NHS and that more competition could create the integration that we need.

One side worries that the status quo of the NHS will be changed by competition, the other that it is needed to change the status quo..

The argument about integration and competition is another round in the argument about how radical improvement can be brought to the NHS.

Clare Gerada was defending the existing NHS’ capacity for integration against the external input that would come from competition and Stephen was saying that what existed within the NHS could not – on its own – create the integration that was needed.

Much of the current debate about NHS reform mirrors these two positions.

Generally one side believes that the NHS – as presently organised – can solve the huge value for money problems that it faces.

Generally the other side believes that the NHS – as presently organised – needs some assistance from external intervention to radically change the way in which it delivers services to meet contemporary needs.

In my day job I facilitate many large and small discussions with NHS staff and organisations. When I watch other facilitators start the day off, one of the phrases I hear often is that “the answer to our problems is in the room”. This is an understandable starting point for a facilitator. The organisation has developed a clear view of the problem it needs to solve. It has brought everyone in the organisation together to work on it; therefore the answer to the problem must be in the room.

This statement builds an expectation among those present that if they work hard enough during the day they can come up with the whole answer to their problem.

I believe that only rarely is the whole of the answer in the room.

It may well be the case that some of the answer is in the room, may even be that most of the answer is in the room, but the notion that all of it is always there is not the case.

And that is the problem for the NHS in the development of integrated care.

As we look at the NHS services that are being delivered in 2011 there is very little internal integration and even less between fragmented NHS services and the other services necessary for patients with long term conditions

On 3rd June I posted about some work I was doing with GP Commissioners in Crawley. The GPs pointed out that about 85% of the services that were necessary to keep the frail elderly happily outside of hospital were not health services. They were a wide range of very different sorts of interventions. The 15% that were NHS services were themselves provided by very different people. Given the NHS has until now not integrated its 15% why should it suddenly become adept at integrating its 15% with the other 85% of the necessary services?

Why, for example, should an excellent orthopaedic consultant be able to integrate a building form to carry out adaptations on a home or a “meals on wheels” provider to come earlier than they have before? Why should that doctor be able to step outside of their very specific skills and be able to integrate several different industries into one seamless patient pathway?

This is a very very complex issue in the logistics of service delivery.

We are asking people who, by and large, have only ever worked in the NHS to suddenly be able to work across those very different industries and bring them together.

This may not be possible, and it may be the main reason that – for the NHS – integration keeps on not happening.

I think we need new providers of integration as a service and a technique in its own right. They will integrate NHS and other services into a pathway and many of them will not come from inside the NHS.

If the different integrators have to make out a case to commissioners and to patients about which is the better seamless service, then the commissioners and the patients will them be able to choose the service that fits them best of all.


One Response to “Does the answer to the problem of creating integrated care lie entirely within the NHS?”

  1. Paul,
    You are way off the mark in understanding the position of the RCGP and the BMA.
    We do not support the status quo, which is a market based system with a PP split. BMA policy is to oppose the PP split and the marketisation of the NHS.

    It is the market system that destroys integration of services. The whole point of the market is to break up the monopoly of the NHS. It is designed to put hospital against hospital (including private and third sector organisations). However, healthcare is a suited to a public monopoly precisely because of the efficiency gains through integrated services, national bargaining with big pharma and the medical devices industry, and economies of scale. There is also the added benefit of reduced transaction costs. (Of course, these systems need very clear and powerful methods of accountability, which I accept have been too weak in the past)

    The pro-marketeers want to maximise the number of providers and “consumers” to drive the competitive process. How could this ever help with integration? It will fragment services.

    Best wishes,

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