Integrated care - lessons from America

Polling shows that in the current American presidential election campaign, health reform is the second most important issue for voters after the war in Iraq. Although media focus is on the debate about universal coverage, this can be achieved only through reform of the delivery system.

The US healthcare structure has been compared to that of a 19th-century cottage industry. Although it includes corporate giants, these are concentrated in the supply sector, providing drugs and devices, and in the insurance sector, where six companies hold 43 per cent of the commercial insurance market.

In the delivery system, where doctors and other health professionals work in hospitals and clinics, the pattern is incredibly fragmented, with 48 per cent of doctors working either in solo or two-handed practices and only 11 per cent of physicians working in groups of more than 10.

The results of this fragmentation are clear. Despite the US being the sixth largest economy in the world with a per capita health spend double that of any other country, its healthcare industry has been ranked as 37th in the world by the World Health Organisation. The 2007 Commonwealth Fund's comparison of the healthcare systems in six industrialised countries looked at quality, access, efficiency, equity and impact on healthy lives and rated the US as the poorest overall, while the NHS was the best.

Yet there are important lessons in US beacons of excellent practice, where several models of healthcare are delivery managed to provide individually tailored high-quality integrated care.

The main focus in the UK has been on learning from large integrated delivery systems, such as Kaiser Permanente and the Veterans Health Administration, or the work of large insurance companies, such as United Health or Humana, in commissioning disease management packages to minimise unnecessary hospitalisation.

However, there are other models which, although built around looser networks of physicians, also have strong and enduring partnerships between doctors and managers at the heart of their business model. These networks may contract from other organisations and some have close links with a specific health plan, but they are all focused on healthcare delivery and are based around healthcare professionals whose main job is treating patients.

Integrated systems

The large systems are usually based around a multi-specialty group practice that employs doctors and manages the provision of medical services to a defined population, either linked with a hospital (as in the Mayo Clinic) or with hospitals and a health insurance company (as in Kaiser). These organisations can be very large; in Northern California, Kaiser Permanente employs 6,600 doctors, about half of whom are primary care physicians of one type or another. In some cases, they are geographically dispersed, with groups of like-minded doctors working in smaller teams in different cities.

Research has shown that doctors working within an integrated system deliver higher quality preventative care and chronic disease management than those working in private practice or in a loose network arrangement. Although the historical data has focused on process measures of quality, there is emerging evidence that integrated systems can also deliver longer life expectancy and operate at lower costs.

One size does not fit all situations and there are other organisational models that tend to be smaller and more diversified. These are often based around networks and use partnerships with contracted and employed doctors and a variety of remuneration systems. These organisations and groupings require a more fluid and flexible approach to both clinical leadership and management and some have made impressive improvements in the quality and continuity of care.

Healthcare in the US is generally separated into ambulatory and hospital care, rather than the traditional distinction in the UK between primary and secondary care. Ambulatory care is provided both by general practitioners and specialist physicians away from the hospital, which is reserved for overnight stays. US integrated care focuses on bringing together family and specialist doctors to focus on improving continuity of care and minimising unnecessary admissions to hospital, although there is rarely any integration with social care.

The combination of insurance plan as funder with the delivery system is a second dimension of integration. The models vary, but include a mutually exclusive relationship uniting the two functions, with the payer and provider operating as semi-autonomous partners under a single management team.

Irrespective of the precise organisational arrangements, this integration means that an ethos of resource stewardship permeates the organisation and complements the drive for quality improvement and the profit motive, which the smaller networks find difficult to emulate.

With no overarching national system or framework, management of the financial risk associated with delivering healthcare is brought into sharp relief in the US system. The usual model is that the risk is held by the insurance company, which sets its premiums and co-payments to cover this risk. In larger integrated systems where there is both a health plan and a delivery system, the whole risk sits with the plan and they have a range of mechanisms to share risk with the physicians and provider.

The strongest mechanisms are usually the cultural and organisational ties between managers and doctors who know their successes and failures are inextricably linked, rather than some complex payment formula.

Insurer prepayment

Smaller systems and networks will accept the risk for some patients through an annual prepaid payment from the insurer; in exchange the doctor will manage and fund all or most of the healthcare for an individual, while most patients will be funded through classic fee-for-service payments.

The capitation model of funding has been declining for the past decade, mainly because patients believe it led to restrictions on care. It might be expected that smaller systems would be more risk averse, but some small groups believe the excellence of their out-of-hospital care means capitation is an acceptable risk.

The ongoing Our NHS Our Future review challenges the NHS to demonstrate that it can deliver integrated care that resonates with patients' experiences.

Integrated structures do not guarantee integrated care. US organisations that describe themselves as integrated are usually not-for-profit companies or foundations. They treat the views and experiences of members and patients as the main mechanism by which to judge their success. They obtain these views through regular surveys and encourage them to participate in the organisations' decision-making processes.

Although US integrated organisations are larger than those emerging in the NHS, there are important lessons in the common features of both the integrated systems and network models in the US. What are these lessons that will help NHS organisations deliver better integrated care?

• Primary care led and reaching into secondary care. The most innovative integrated organisations focus on provision in primary care and community settings with "in-reach" or "forward" integration into the hospital.

• Medically or clinically led but based on a partnership with management. In most US provider organisations the medical leadership takes responsibility for clinical quality. But medical leaders in the successful integrated organisations work as partners with managers on an approach to clinical and service quality and use of resources that generates a strong focus on organisation-wide performance improvement.

• Has health IT at its heart. All the successful US integration projects have invested in IT. Large organisations have invested huge sums in comprehensive electronic medical or health records, but smaller networks have created quasi-web-enabled systems that link together the different systems owned by independent doctors' practices.

• Focuses on chronic disease management and population health. These organisations recognise significant scope to improve services for people with chronic conditions and that the integration of services is part of sustained improvement. They drive change both at the level of individual patient and at the population level.

The diverse US models show that organisations of varying size, portfolios of services and strengths can co-exist. However, the lessons for the NHS are not really about how these models interact - they are poor at co-ordinated care - but about how they achieve excellence within their boundaries through integrating the work of managers and doctors and of payers and providers across the primary and secondary care sectors.