Two sets of articles, one from each side of the Atlantic, recently caught my attention. Each is of some interest in its own right, but taken together, they set my health policy imagination alight …

The first was a Perspectives piece in the New England Journal of Medicine with further interviews (and some illuminating readers’ comments) in a subsequent New York Times blog. It seems the traditional model of US healthcare provision – small independent physician-owned practices separate from the hospitals that provide facilities for diagnostics and inpatient beds – is changing to one where more than half of practising US physicians are now employed by hospitals or integrated delivery systems.  (My own US experience reflects this: my choice of primary care provider was mainly between those working as part of Jefferson hospital system or those working through University of Pennsylvania hospital system.) Why? Because physicians are deciding that employment offers them less bureaucracy and a better work-life balance than the ‘Mom & Pop store’ model, and they’re happy to trade that off against the decreased autonomy and increased performance management that come with employment. By employing physicians who had been using their facilities, hospitals capture those physicians’ patients in what they hope is increasing market share. And both physicians and hospitals potentially benefit by being better prepared for outcomes-based payment reform. From the patients’ perspective, the removal of fragmentation between hospitals and physicians can potentially produce a more co-ordinated, faster service with less chance of overuse or misuse of care, and if they don’t like the service provided then there is sufficient capacity within the market for them to choose another provider.

In England, attempts to get GPs and hospitals to work together seem perpetually to have been foiled by the same health policies that should have brought them together. GPs with specialist interests have been seen as both friend and foe by hospitals, depending on the degree of collaboration versus competition between the two. In my experience, practice-based commissioning helped and hindered closer professional ties in almost equal measures. And GP consortia? Who knows …

Which brings me to the second set of interesting publications last month: a report by the Co-operation and Competition Panel (CCP) summarized by the HSJ, describing their decision to approve the acquisition of three GP practices by an acute hospital trust, and by setting this precedent, also to approve a small number of similar acquisitions elsewhere in the country. The terms of the approval are explicit about how such mergers should not diminish a patient’s ability to choose hospitals, and patients in affected practices should not feel obliged to choose the acquiring hospital. Furthermore, the CCP states that it has concerns about such acquisitions having a “material adverse effect on patients and taxpayers”.

But surely, this statement by the CCP overlooks the opportunities and potential benefits that could come from integration of primary and secondary care. Indeed, as described above, market pressures in the US are driving providers to reorganize in just this way, and, as both the NHS and US markets plan to implement outcome-based payment systems, at least some of those market forces are common. Unlike the US, the NHS has the advantage of a single payer for healthcare, reducing administrative complexity for any merged (dare I say ‘integrated’ or ‘accountable’?) organisations and returning any cost savings from integration to the wider system and the tax payer.  So, rather than being viewed – by the CCP at any rate – as a potential problem, such organisations may well be a potential solution to a number of testing problems.

However, to be truly integrated rather than just merged, these new organisations must overcome a number of persistent issues. For example, financial flows that favour hospitals may be only partly alleviated by payments for outcomes because of the time taken to devise and implement a comprehensive set of such funding flows. Furthermore, patient flow from the affected practices will comprise only a small fraction of the total referral flow into those hospitals, and therefore may be viewed by each hospital as merely inconsequential to their overall operation. And, as the CCP’s response indicates, the merged organisations are starting out in a policy environment in which choice and competition suffocate collaboration and integration.

To overcome these issues will require imagination and commitment by clinicians and managers, and political aircover at the very least. (Political championing would be better, perhaps using the opportunity that QIPP presents.) Now is also the time to consider a robust evaluation of the transition of these merged organisations into integrated organizations and the benefits that integration is able to provide. Indeed, when will there be a better way of assessing in the NHS the benefits of closer integration between primary and secondary care?

Just imagine: evidence-based policy making …