Massachusetts has been at the forefront of American health reforms, and as early as2006 passed legislation requiring all citizens to take out health insurance. Subsequently attention has turned to different payment mechanisms and organisational reform in an attempt to achieve the dual goals of improving quality and controlling costs.
Atrius Health is a not-for-profit alliance of five medical groups in Boston that have joined together to improve care. These groups – each with its own culture – provide care for more than 700,000 patients in 30 locations and include doctors working with more than 35 different specialties.
The experience of organisations such as Atrius Health is that smaller practices benefit from having access to the skills and capabilities of the larger group, particularly in managing secondary care services. Atrius Health also provides an accountability structure that ensures constituent practices are held to account for the quality of their care.
Critically, these medical groups comprise specialists as well as general practitioners and this facilitates the provision of care in the community where appropriate. We visited medical groups who demonstrated a relentless pursuit of both quality and cost-effectiveness, particularly by their proactive approach to the management of long-term conditions and their comprehensive in-reach services into hospitals and nursing homes.
Doctors known as ‘hospitalists’ – specialist physicians working in the community as well as in hospital – were widely used. Undertaking daily reviews of patients, they acted as transition co-ordinators and case managers working to move patients out of hospitals. A similar rigour was applied to skilled nursing facilities (our equivalent of nursing homes). These strategies yielded impressively short lengths of stay and a low use of hospital beds.
The same thoroughness was applied to challenging variability within medical groups, supported by peer review and openly shared performance data. It was accepted within these groups that individual clinicians would be held to account for variability in performance and this was addressed through a mixture of “carrots and sticks”. This was an accepted part of the organisational culture and was led by experienced medical directors unafraid of having difficult conversations with their peers.
So what could the NHS learn from this system? Our commissioning consortia will need to address the very significant issue of variability that exists in primary care and learn from the experience of medical groups in the United States. This was highlighted in our inquiry into the quality of general practice, which demonstrated widespread unwarranted variations in care. Consortia will need to have the capacity and capability to tackle these variations.
Although there are important differences in the funding and provision of health care between England and the United States, the parallels are too important to be ignored. The medical groups that make up Atrius Health took on capitated budgets several years ago, moving away from the previous inflationary fee for service contracts. Capitated budgets allow groups to focus on the issues they feel are important and link to the achievement of agreed outcomes, indicating the shape of things to come in the NHS.
Medical leadership shone through all the organisations we visited. Commissioning consortia will need to put in place excellent management support and invest in high-quality medical leadership. The emphasis placed on multi-specialty medical practice in the United States and the benefits this confers in enabling medical groups to redesign services and make less use of hospital beds is a key lesson.
The ‘pause’ in the passage of the Health and Social Care Bill should be used to reflect on how this and other lessons from the United States can be incorporated into plans for the NHS in the future.