Jamie explained that medical groups in California take various forms: no one group achieves superior performance and all face similar challenges. Three of the issues faced by US medical groups are particularly relevant to clinical commissioning groups.
First, the doctors and practices that make up groups need to feel a real ownership of their work if they are to succeed. Ownership hinges on the quality of medical leadership and the development of a culture of followership among member practices. In California this was facilitated by the fact that most medical groups serve relatively small populations – usually fewer than 100,000 patients and often much smaller.
Second, many medical groups in California went out of business, failing to develop a sense of ownership among practices or lacking the capabilities to manage budgets and services. These capabilities include financial management, care management processes and programmes, and information technology. An early predictor of a successful group was one that considered the potential risks of rapid growth and planned for the consequences.
Third, medical groups realised savings mainly through reducing inappropriate use of hospitals. They were able to do so in part because they comprised some specialists as well as family doctors. The model of multi-specialty medical practice in California enables more care to be provided in community settings, with hospitals being used only when necessary.
England is not California and lessons from abroad must be treated with caution. Nevertheless, there are clear implications for clinical commissioning groups in relation to: their size – small may be beautiful; leadership and management capabilities – these should be essential; and the opportunities for GPs to forge stronger links with specialists.
One other lesson will be much more difficult for the NHS to take on board. Medical groups in California are not mandated by government but are established by doctors themselves when they see the benefits of collaboration. Whether the conscription of GPs into clinical commissioning groups defined by geography rather than affinity can deliver the benefits the government hopes remains to be seen.