Our integrated care summit on 1 May featured innovations in integrated care from across the world. There was also a guest appearance by Andrew Lansley as part of a Dragon’s Den session to assess three examples of integrated care in England. At the end of the session, Torbay’s well-known work on health and social care integration narrowly beat an innovative programme in north west London on integration for people with diabetes and older people in a vote among the 200 participants at the summit.

 But the highlight for many of those who attended was an inspiring keynote address by Ken Kizer who led the transformation of the Veterans Health Administration (VA) in the United States in the 1990s. Kizer told a gripping story about how he led the shift away from a fragmented hospital-centred system to an organisation based on 22 integrated service networks. During his five years in office, the use of hospital beds was reduced by more than 50 per cent and the quality of care improved markedly.

Kizer’s story is in large part an illustration of the power of effective leadership. On taking up his post, he moved quickly to shape a new vision for the VA, agreed a new structure to help implement the vision, and ensured the right people were in place to make it happen. Leaders of integrated care service networks were held to account for the delivery of performance goals – expressed mainly in terms of the quality of care to be delivered – and the performance of different networks was compared in regular meetings of network directors.

When Kizer arrived at the VA it was widely thought of as a hospital system. During his tenure the business of the VA was redefined as that of a health care system providing the full continuum of care with a focus on the delivery of high-quality health care. This aspiration was supported by the implementation of an enterprise-wide information technology system including an electronic patient care record, and the deployment of telehealth to support veterans living in the community.

Two of the lessons from the VA are especially relevant to the NHS in England. The first is to see acute hospitals as cost centres instead of profit centres, and to ensure that their role is proportionate to the needs of the population being served. The ability of the VA to make substantial cuts in the use of beds lends support to the argument that the NHS has more to do to make a reality of care closer to home.

The second and related lesson is to align payment systems to facilitate this objective. As part of the VA’s transformation, integrated service networks were funded through capitated budgets and network directors were able to use savings achieved through reducing the role of hospitals to build up services in the community. The obvious question for the NHS is how to move to a similar set of aligned incentives to support the further development of integrated care?

The outlines of an answer to this question emerged in work led by Kizer later in the week of his visit with a group of health economies in England who are well advanced in the development of integrated care. Many of these economies have, in effect, suspended the normal operation of Payment by Results. In its place, they have agreed sophisticated block contracts for providers that focus on quality improvement and allow for risk sharing between providers and commissioners.

The moral of this story is that local leaders – not for the first time – are ahead of the game, even if they risk incurring the wrath of the regulators in deviating from standard operating procedures. If integrated care is to emerge at scale and pace, the NHS needs more positive deviants, and the powers that be should learn to actively encourage them to show what can be delivered when they look out instead of up. Perhaps the time of deviant leaders has finally arrived.

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