Peter Reader on integrating healthcare

For the first time, we have the opportunity to challenge the greatest sacred cow in the NHS - the artificial division of primary and secondary care.

For years, this has been one of the greatest barriers to patients receiving the best care. NHS history, indeed some of the very building blocks on which the medical professions as currently defined are built, and the lack of appropriate structures in primary care have until now formed an apparently insurmountable block to this path being pursued. And yet in just a few months the acorn of an idea, championed by a few who have already started to put it into practice, seems set to sprout forth from the Darzi documents.

So how and why is this to be delivered? The simple answer is that by developing integrated provider organisations, vertical and horizontal integration of services across the artificial primary/secondary divide will mean whole patient pathways and complex packages of care can be delivered seamlessly in a single organisation.

The careful aligning of financial and structural incentives across the whole patient pathway will ensure that freed-up resources from prevented hospital admissions can be invested in new services and health promotion without destabilising the acute end of the provider. The lessons from Kaiser and similar organisations show us that this is possible and clinically desirable, and that it opens new possibilities for aligning clinicians' needs with those of the patient and healthcare system.

Challenges ahead

Lessons from abroad also show us how world class commissioning can and should be part of these integrated provider organisations, and how the stimulus of competition is not necessarily lost as it can still exist between such organisations. Indeed, the nirvana of patient choice driving up quality of care may well be overplayed given that patient feedback gathered as part of the Darzi project highlighted that patients value quality local services over choice. Should we be so tightly wedded to choice if it stands counterpoint to solutions that really can deliver radical improvements in the nation's health and healthcare? Will choice ever really be a force in rural areas?

We must be under no illusions that integrating care in this way would be an easy task. There are plenty of examples that teach us that simply putting people into the same organisation does not make it integrated or functional. Lessons from abroad tell us that many years may be required to deliver truly integrated services with strong clinical leadership running through the service. This change will therefore require significant investment into development and support in order to deliver the organisational identity and shared focus. The NHS does, however, appear to be waking up to the need to invest in such management and clinical leadership development, so perhaps the timing is right here too.

So do we have the courage to change this first faltering step into a leap that would radically alter the NHS healthcare landscape? It requires radical thinking, an acceptance of change beyond any yet attempted, and a shift in the traditional clinical model of patient care in the UK. Yet I believe the rewards for patients, professionals, communities and the NHS could be equally enormous.