Lessons from America: achieving integrated health systems

In a recent speech to the BMA, Andrew Lansley argued that separating the management of care from the management of resources was a fundamental weakness, adding, 'examples in America of physician-led, more integrated services, demonstrate how differently – and effectively – they can deliver care.'

As someone who has studied integrated delivery systems in the United States, and having just returned from Boston where I saw this first hand, I strongly support the Health Secretary's comments. The challenge facing the government is to use the opportunities presented by the health White Paper, Equity and Excellence: liberating the NHS, to move the NHS in the direction of these integrated systems and to emulate their achievements in delivering high-quality and responsive care at reasonable cost. GP commissioning provides a basis for doing this provided that four key lessons from US experience are heeded.

First, GP commissioners must be allowed to take the 'make or buy' decisions that will help to improve performance in the NHS. Only if GPs are able to use their control of resources to provide more services directly will it be possible to offer real alternatives to hospital and to stem the rise in emergency admissions. Of course, commissioners must be held to account for their use of budgets, but simplistic arguments about conflicts of interest should not be used to prevent primary care teams from doing more to manage demand in the community.

Second, commissioning should be used to achieve closer integration between GPs and specialists. In the US, multispecialty groups of doctors are at the heart of integrated delivery systems and are able to provide many forms of diagnosis and treatment without recourse to hospitals. GP consortia will be operating on a sufficient scale to bridge the historic division in British medicine if the government is willing to let this happen.

Third, multispecialty medical groups work hand in hand with health insurers to redesign care pathways and to ensure resources are used efficiently. Health insurers provide infrastructure support to medical groups as well as assistance with contract negotiation, claims processing and data analysis. GP commissioners must be able to access similar support if they are to realise their potential, although where this will come from following the proposed abolition of primary care trusts is not clear.

Fourth, as Andrew Lansley indicated in his speech to the BMA, a cadre of GP leaders will be needed to take forward commissioning and to achieve closer integration of care. GP leaders will need support from top-class managers, while also being able to call on technical expertise in developing new models of care. GP commissioners must have adequate resources for this purpose, even if management costs are being cut back.

The reform programme set out in the White Paper offers a radical vision of the future and its potential will be realised only if policy-makers are willing to heed these lessons as their plans are worked up in more detail.

This blog was also published on the BMJ website

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#181 Dr Paul Worthington
NHS Project Manager

I agree with Prof Ham's views in relation to the need for effective leadership and for putting the multi-disciplinary voice front and centre in service redesign. Equally, primary and community care must have a significantly changed and enhanced role. However, Prof Ham's comments about quibbles on conflict of interest are pointed and well made; the White Paper proposes that the NHS Commissioning Board picks up commissioning lead on primary care services. To drive one of the key potential levers for change further away from local decision-making has to be questioned.

#187 Jonathan Sheldon
Consultant Physician and Medical Director
Queens Hospital Burton

I fully agree with Chris Ham as also just been to see KP working. However the difference between KP and the NHS is that ALL their Doctors work for the same locality and until GPs are employed in the same way as the consultants there will always be a problem with transfering care, sharing facilities and simply both primary and secondary attempting to remain solvent. I believe that the Goverment should joing primary and secondary care into one locality health unit with 'salaried staff' who all work for the same organisation with same checks and balances, appraisal and loyalty to the Locality and not to their 'own' organisations.

#188 lhaslam
student nurse

My limited experience of MDT meetings has shown that medical input forms a small contribution to decisions on patient management. If the holistic paradigm is to be maintained then i dont believe a range of medical specialists will be sufficient in all decisions. GP consortia will have to involve a wide range of specialists from the voluntary, social and community health sectors in their commissioning. This is especially true of care environments with limited medical input such as rehabillitation, palliative care and intermediate care. If GP consortia decide to outsource their budgetry management there will be increased uncertanty.

#189 Matt Graham

My understanding of the integrated systems in US is that having joined a particular system, eg KP, choice is limited to the institutions within that system. What I don't understand is how the UK system, either currently or as proposed in the White Paper, can include patient choice but also have a system of commissioning. Doesn't choice undermine the integration of the system which could be achieved through GP commissioning?

#190 patricia Maxwell

As a British subject living and working in the US. I totally abhor the idea that Britain should follow the health service of the US. Health Care is vastly too expensive. The elderly are being forced to choose in many cases whether they afford their care, medications etc or put food on their tables. Insurance companies are costing more and more and providing less and less. The poor are getting less care as the rich get more. Now the present administration is trying to emulate the British Health Care system more and I approve of this.

#199 Joe Lamb
retired medic professor

One of my sons & family lives in the US in San Diego. Half the large cost of medical care is paid by the company else he couldn't afford it, like some 40 million citizens who can't. Chris Ham should get out & about in the US & talk to ordinary people who have no health cover & fear getting unwell. He should think of the NHS in half full terms rather than half empty ones & keep quiet.

#204 liz bloomfield
norfolk community health and care nhs trust

why do we always follow America? having worked in the USA their health system is totally different to ours, all GP's are specialist and little consultants. most of the hospitals are private and you need insurance. there are state hospitals for the less well heeled and good they are too.
we followed this route with nurse training and it has not been good. i feel they need to rethink or just admit we may go to the private sector!!!

#205 Rob Billson

I find the complacency of Chris hams article astonishing. the "Integrated health Care systems" of the US may well be efficient but they are beyond the financial reach of very many less well off people. The NHS in this country is treating far many more people for a much greater range conditions than the US system, proportionately and in this country a serious health problem is not also a financial disaster for the unfortunate sufferer. If we really want to emulate health care systems in the Americas perhaps we should look to Cuba, whose citizens enjoy longer, more disease free lives than their US neighbours, at afraction of the cost.

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