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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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If integration of NHS care is the answer, what exactly is the question?

Filed Under (Competition, Kings Fund, Patient Choice) by Paul on 03-06-2011

One of the more interesting aspects of the period that the Government has taken to have a bit of a think about its reforms has been the way in which organisations that have had a long term solution to the problems faced by the NHS have used this space to suggest that their solution can solve its problems.

For some time the King’s Fund have been suggesting that integrated care is the solution to the real problems of the NHS and towards the end of the current pause they used the opportunity to restate that case.

“The King’s Fund has called for significant changes to the government’s health reforms to enable the NHS to provide a ‘new model’ of care that meets the challenges of the future.

In its response to the government’s listening exercise on the Health and Social Care Bill, the Fund says it supports the need for reform but argues that it must be based on a clear diagnosis of NHS performance and the challenges it faces. It calls for the NHS to be re-orientated to deliver a new model of ‘integrated’ care, based on stronger collaboration between health professionals and more effective co-ordination of services.

The response argues that integrated care offers the best prospect of improving services for patients and addressing the key challenge facing the NHS – demographic change and the increasing number of people with long-term conditions such as diabetes, asthma and dementia. It draws on evidence from the NHS and the United States showing that integrated care delivers better outcomes for patients with long-term conditions and improves the quality of specialist services such as cardiac, cancer and stroke care. ”

The case for integrated care is a strong one. One that has been made for at least the last 7 years since evidence from Kaiser Permanente in the USA demonstrated much lower utilisation of hospital beds than by the NHS. The problem for the King’s Fund and others who are arguing for much greater integrated care is that the NHS, with its own skills and capacities, has not been able to develop integrated care in any substantial way.

Those arguing for greater integration say, quite rightly, that greater co-operation is needed between the various parts of the NHS – and, as I will argue, other very different services as well. The argument that integrated care should happen is a straightforward one. The reasons it continues not to are more complex.

In the last few months many commentators have claimed that the extent of competition within the NHS reforms cuts across the collaboration that would otherwise exist between its organisations.  A few weeks ago the Royal College of General Practitioners provided its own advice to the Government about its reforms when it said,

“33         The Bill seeks both competition and better integration, which can be seen as mutually exclusive; it is difficult to see how competition rules could be framed to deliver both of these objectives. The fear is that it will no longer be possible to deliver integrated services in practice, especially where integration relies on close collaboration between different providers and commissioners, and could be seen as anti-competitive.”

The RCGP is not alone is seeing competition as being in some way against integration.

But,  as I commented in a previous post, most private sector products are the result of both competition and co-operation. You compete with some organisations and you co-operate with others. To obtain any significant service product takes the co-operation not just of separate organisations – but of very different industries. All of these services are developed co-operatively within a supply chain of those different organisations.

A consumer buys a loaf of bread competitively between different bread retailers. They choose between providers on quality taste and price and a wide range of important issues. That loaf of bread has been created by a very, very complex set of industries working closely together to provide an integrated outcome. The same retailer can provide an enormous range of different goods services which are also provided by very complex co-operation between organisations and industries.

The more complex the product, the more important the co-operation has been, and often, the more competition has taken place.

A word on Kaiser Permanente. I know that those in favour of the reform of the NHS must not mention the US because we are now in a period of time when everything that comes out of the US is “wrong”, but many people who believe in integrated care believe that Kaiser Permanente is a case where integration has happened because they are not in competition. They make the case that all the patient pathways are created with their own staff and are fully integrated between each of the parts of the organisation. So where’s the competition?

When you talk to the people who run Kaiser they find this an amusing idea. They point out that every aspect of their model springs from a competitive process because each person or employer who decides to have their health care organised by Kaiser does so in competition with many other health care providers. The member of the public, or the employer, can choose regularly to move either to or from or Kaiser Permanente if they are not provided with the best health care. If they fail to compete well and to provide the member of the public – who may well be state insured – with a proper choice of health care, they will not be chosen. The co-operation that Kaiser Permanente have as their hallmark gives them a competitive advantage over their health care competitors. The more they improve their capability to co-operate in providing better pathways, the better they can compete.

That is why to develop integrated care for NHS patients we need stronger and clearer competition between different integrated care providers. Some of these existing providers of services that need integration may well be NHS integrated care providers and some will have been providing services that are not health services at all.

I was helping with a workshop the other day which had GP commissioners and the voluntary sector looking at patient pathways. They were working on the development of an integrated care pathway for the frail elderly. They started from the supposition that to make this pathway really work and keep frail elderly people out of hospital, about 15% of the services were health services and 85% came from other providers.

You needed integration with either the social housing provider – or at the very least with a firm that would provide aids and adaptations for the older person – and you needed that to happen – not within 2 or 3 months – but, if you were really to keep someone out of hospital, at 40 minutes notice. You needed very good integration with the social care provided by the local authority, a much clearer and better set of integrated services from the voluntary sector for carers, and with the older people themselves.

It’s true you needed much better integration between GP services, community health services and hospitals. But to make this work you needed one integrated service of all of these different services – not just NHS care.

This looked and was very complex and we felt that to really make this happen the GP and local authority commissioners needed to be clear about the desired outcomes and to tender for an integrated service to provide them. A wise commissioner would ensure that some of the older people themselves were a strong part of this commissioning process. Hopefully this tender process would result in three or four different integrators weaving together – from the myriad of constituent providers – a strong and capable pathway.

The main contractors will probably have as a part of their pathways similar, if not exactly the same, sets of local providers. What will be different between the different sets of competitive bids for the pathways would be the way in which all of these different providers were brought together. What the commissioner would be buying is expertise in strong integration, and competition between integrators would create better and better methods of integration.

One of these could well be an NHS provider. It may well be the case that a lead clinician in a hospital has the capacity to develop a set of integrated services between three or four different industries and to make that work in such a way as to reduce emergency admissions to their hospital. In order to win this competition they would have to demonstrate a very new capacity to integrate not just with other NHS providers but with the very wide range of other services that must be integrated to create a strong pathway for people with long term conditions to emerge.

For integration to really enter the NHS delivery chain we will need much, much greater expertise in the very difficult process of integration itself than exists at the moment.


One Response to “If integration of NHS care is the answer, what exactly is the question?”

  1. Paul,
    Thank you, as ever, for a very thoughtful piece on integrated care and the NHS reforms. Like many other commentators I have failed to see the connection between the pressures on the NHS which drive the need for reform and the proposed reforms themselves. As you say it does appear that integrated healthcare systems are worth looking at as a mechanism for addressing the increasing costs of chronic disease and an aging population.
    The lesson I take from Kaiser Permanente, Geisinger and the like is that you have to operate competition at the level of the patient rather than the disease or symptom/risk. Competition in the NHS to date, and this is continued and exacerbated in the proposed reforms, has been at the level of procedure or service. While a system of integrated care within the GP practice and referral to “competed for” services works well for families who are generally well but occasionally require an investigation or hernia repair it works appallingly badly for those with complex and chronic conditions. If you or your relatives have received care for such conditions from the NHS, social services etc. you will have appreciated first-hand how uncoordinated, disorganised and even dangerous, it is.
    I also agree that supply chains are very important and that competition is necessary for an effective supply chain. But the literature and case studies that exist, and my personal experience, show that there is a large scale effect because modern supply chains are a mechanism for balancing profit and risk which require management and are driven by access to customers. Trying to commission an integrated service for a segment, such as the frail elderly, within a GP consortia will not result in a strong effective supply chain because for both the manager of the supply chain and the subcontractors there is not a sufficient scale to justify moving from transactional pricing.
    Giving the responsibility for commissioning to GPs will perpetuate this problem because of the inherent conflicts of interest and the historic tensions between GPs and specialists. It is unlikely that an initiative such Medicare’s use of telemedicine to manage a cohort of patients outside of their primary care provision, and at a much lower cost, would ever be commissioned. Similarly GP commissioners would be unlikely to commission Kaiser Permanente’s initiative in Hawaii where renal specialists review the data of patients in primary care to identify those who would benefit from specialist intervention to slow the course of their disease.
    The relative success of integrated healthcare systems in terms of quality and cost control compared with the health insurance model in the US has led to Medicare’s policy of contracting with “Accountable Care Organisations” (who are responsible for all of an individual’s care). In the context of the NHS one would have to achieve a transition from the current state to one in which provider groups that included primary and secondary care had overlapping geographies enabling patient choice and spurring improvement through competition.

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