Stephen Eames on large scale health solutions

In the first year of the second greatest recession in a century, why do we continue to consider setting up new organisations to deliver community services, further crowding the space between hospital and community doctors?

Last year’s operating framework encouraged vertical integration, provided it was in the best interests of patients and the taxpayer. This year, as the government struggles to cope with meltdown in the financial sector and global recession, the mantra is quality, innovation and productivity. If we are to save something like £15bn-£20bn from 2011 on, one thing we really must do is systematically address this hoary old chestnut.

I know some people will say the last thing we should be doing at the moment is restructuring but that is exactly what the large corporations are doing in the face of tough economic conditions.

So here is my “manifesto” for implementing vertical integration swiftly.

• The patient experience will be better because there will be greater capability to provide more single points of access and assessment. Incentives to improve co-ordination and communication between GPs and hospital doctors would be stronger so fewer patients would need to attend multiple venues for diagnostic tests, consultations and treatment. Better targeted use of specialist intervention, skilled practitioners and new technologies would mean that innovative schemes for treating patients at home or in communities would be more likely to come to fruition. This is a once in a lifetime opportunity to integrate the activities of generalists and specialists in primary and secondary care around the patient rather than organisational need.
• Delivery of Darzi models of care will be swifter and easier because integrated urgent and emergency care services will ensure patients move along the right pathway first time, every time. Use of nurse practitioners and integrating GP out of hours and hospital services will save costs and the door will be open for delivering day surgery and diagnostic, outpatient and rehabilitation services in community based settings, reducing costs from unnecessary hospitalisation and inefficient outpatient departments. There will be greater momentum towards integrating community and hospital based specialty teams in dermatology, respiratory medicine, cardiology, rheumatology and diabetes services in community based facilities with no organisational boundaries to get in the way.
• Systems and performance will improve because of improved capability to eradicate delays in requesting tests and results reporting. Integrated governance systems will be easier to introduce without organisational boundaries. A single focus will also create the environment for more effective delivery of patient care pathways and protocols, and integrating business practices and systems will lead to better capacity planning and stronger performance management.
• Waste will be reduced and significant amounts of money will be saved because demand will be reduced in secondary care. There will also be less fragmentation of service provision and duplication of activities. Integrating community and hospital based staff will be easier to do, allowing for swifter development of workforce plans that enable more effective use of generic skills, rotation between different parts of the service and economies of scale. A single focus across the patient pathway will ensure that productivity improvements and reducing costs will be easier to introduce and have greater scope to deliver. Management costs and bureaucracy will be reduced.

Performance on integrating services in the UK has been miserable. The new integrated care pilots are pointing the way but are too small scale and often lack ambition. In County Durham and Darlington we have one of the larger pilots. We are ceding control to those at the front line to deliver better, more cost effective services. Strong local commissioning is giving us a sense of direction by wielding the power inherent in the world class commissioning framework and using our combined spending power to deliver financial returns.

We need to move forward quickly, adopting large scale models that make most sense in each health economy. We should not baulk at the idea of mergers; I don’t think the co-operation and competition panel would be too concerned if large scale change led to better patient care and more cost effective services.

Whatever we do though, we should avoid setting up new organisations just to manage community services. How can this possibly represent value for money when there are already enough organisations on the pitch to deliver cost-effective vertically integrated services?

You can believe I am taking advantage of the economic storm to peddle a predictable argument for radical action. I am prepared for my “manifesto” to be regarded like a bag of bananas left too long in the sun. I leave you with the words of Machiavelli: “Nothing is more difficult than to initiate a new order of things.”