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 was 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 with which to hit the coalition on this. 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 in 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 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 1,000 people who are essential in their area to developing an integrated service for mental health. These 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. While 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 they have been successful in.

For the NHS I hope there will be a range of different answers to this. But one of the answers must be found in the weight and power that the “integrator” has in changing all those siloed cultures in order to deliver integrated care. This cannot be done by a committee of all the different and previously unintegrated providers.

My experience of committees of everyone is that they do not have the power to change anyone. This is an example of the problem of believing that integration only comes from cooperation.

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 one that holds the overall contract and can therefore demand integration as a part of the service.

So where does competition come in to 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 healthcare 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 am saying the integrator in any model is going to need some real power to make integration happen.

Paul Corrigan is a management consultant and executive coach, For examples from Paul’s article go to