Now that the government accepts that integrated care has a major role to play in the NHS, we must avoid the pitfalls that could prevent it delivering proper benefits to patients, argues King’s Fund chief executive Chris Ham.
Debate about NHS reform pitches those who advocate competition against those who oppose the very thought of markets having a part to play in healthcare.
Enter this debate Michael Porter, Harvard Business School guru and well known analyst of corporate strategy and international competitiveness. With fellow author Elizabeth Teisberg, Porter has written a devastating critique of the role of markets in healthcare in the US.
Porter and Teisberg’s core argument is that healthcare in the US suffers from “the wrong kind of competition”. By this they mean that healthcare is characterised by cost shifting, attempts to capture patients and restrict choice, and competition by providers to increase bargaining power. The alternative they favour is value based competition, based on the approach found in sectors like airlines and telecommunications, in which providers compete on the outcomes they deliver.
I was reminded of this argument, first published in 2006, when I was thinking about the vogue for integrated care, as exemplified by the NHS Future Forum’s report. As a long-time advocate of integrated care, I am excited the government now accepts it has a role in the NHS.
But the wrong kind of integration can take a number of forms. The first involves integrating organisations while leaving services and clinical teams as fragmented as they have always been. Clinical and service integration should be given priority, with the focus on joining up care around the needs of patients.
A second trap to avoid is to integrate mainly around chronic diseases rather than populations. While integrated services for people with diabetes and other conditions could offer benefits compared with current services, there is a risk they will create new silos.
The main exception relates to specialist services, where networks of providers do have a part to play.
A third danger is that integrated care results in patients being denied choice and services being inefficient. Systems like Kaiser Permanente perform well because they leverage the benefits of integration within a single system and know that members can vote with their feet. Promoting choice and competition as well as integration should be the priority.
A fourth risk is to see integrated care as a sideshow involving small-scale pilots, with competition being the main game in town. If the government is serious in its endorsement of the Future Forum’s advocacy of integrated care, it must demonstrate its commitment by putting the best civil service brains on the case and ensuring that the mandate given to the NHS Commissioning Board has the promotion of integrated care at its heart.
What then needs to be done to support the right kind of integration in England? The King’s Fund is working with the Nuffield Trust and the Department of Health to answer this question.
Our starting point is that integrated care needs to be taken forward at scale and speed if the NHS and its partners in local government are to rise to the challenges. This will only happen if organisations commit to work together through networks and alliances focused on the needs of patients. Virtual or contractual integration is the best way of achieving this.
The main focus needs to be on promoting clinical and service integration for populations such as frail older people with complex needs. Government needs to remove barriers to integration, drawing on a new report I have written with Nuffield Trust colleagues. These barriers include payment systems that reward activity rather than continuity, and regulation focused on organisations rather than systems of care. Equally important is the need for the Commissioning Board to work with Monitor to harness the benefits of collaboration alongside competition.
A recent review in Scotland found that strong leadership between the NHS and councils underpins successful partnership working. The same applies in England, where government can provide a supportive context, but much hinges on local leaders developing a shared vision and commitment.
- Acute care
- Competition and co-operation
- Department of Health and Social Care (DHSC)
- Government/DH policy
- Health inequalities
- Integrated care
- King's Fund
- Long term conditions
- Multidisciplinary care
- Nuffield Trust
- Older people’s services
- Patient experience
- Primary care
- Service design
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