Integrated care and why the NHS needs more deviant leaders

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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Comments

#1178 NKingston
Lambeth LINk

And the most positive deviants will be those who look beyond the narrow confines of CCGs and Acute Board hierarchies and out into the community. There are some rare organisations ,where on evaluation, the positive deviant leadership shines through. These are the projects which ensure that each team member - particularly citizen volunteers - assess their worth as of equal value, and where team productivity then soars. But who is recognising and spreading this approach?

#1179 David Payne
Editor, bmj.com
BMJ

Dear Chris, agree with your take on Kenneth Kizer. I too enjoyed his keynote address and the Kings Fund was kind enough to arrange a slot with him afterwards. Our podcast interview with him is here bmj.com/podcast/2012/05/11/gavi-ghana and the accompanying feature about Kenneth's career here bmj.com/content/344/bmj.e3324

Kenneth is credited with introducting electronic health records a the VA, but I liked his suggestion that technology isn't as important as culture change bmj.com/content/344/bmj.e3178

#1180 calum paton
Professor of Public Policy
Keele University

Chris, I could not agree more.....which begs the question: why have you spent the last 21 years supporting reforms which dis-integrate care in England? You could not make it up!
Calum Paton aka Grumpy Old Scotsman

#1181 Peter Durrant
Retired social/community worker

As a seventy-something person living alone with a community/social worker background I am appalled by the lack of creative thinking to involve lonely people - and I now live alone following my wife's death seven years ago - where it is incredibly difficult to find structures that enable people to become integrated members of, arguably, welcoming organisations helping us all to make a contribution. I am reminded of the news this morning of the 83 year old guy who donated altruistically his liver and his statement that it is important to feel one is still able to make a contribution. For me in spite of joining various third sector organisations as a 'volunteer' - as opposed to a valued unpaid partner whose life experience and professional background is valued - too often one finds oneself in token 'trustee' roles where, over-individualistic vol-orgs fail to take, as one ages, a politically sharp and criticil view of welfare state in general. Local authorities, not-for-profit and other groups could use us our many ideas as willing unpaid 'contributors' to make, at our own pace, quite unique observational and practical contributions. But, in reality, in spite of once good connections,and strenuous attempts to offer one's services, there is never a response. Community work in my day, he said nostaligically, was about enabling and facilitation, grass-roots upwards thinking, conscious devolution of power and radical networking. Which, sadly, seems no longer the case. Peter Durrant.

#1182 calum paton
Professor of Public Policy
Keele University

Should have added (to prove I'm an anorac as well as a Grumpy Scotsman ): I believe that Kenneth Kizer was short-listed when the government was replacing Nigel Crisp as CE of the English NHS in 2006. Instead, of course, David ('Auld Nich') Nicholson was appointed.

Will the NHS encourage 'deviant leaders'? Will Kim Jong Un renounce his daddy? Will Ahmadinejad apologise for rigging elections?

I suspect the DoH is keen to import many things from the US (eg market chaos; the lovely phrase, 'kiss up, kick down') but its very own island of socialism? I doubt it!

#1183 Ol Mighty
PCT

I remember the development of the national integrated care pilots, especially the event which launched the application process. The overriding message which was asked - "what rules can we break?".

Interestingly enough, the people in charge of choosing the pilots denied all knowledge of this question being posed, because I asked them directly at the announcement conference. Says a lot about the perception of innovation in the nhs.

#1184 Martin Roland
Professor of Health Services Research
University of Cambridge

Since so many of the US examples of 'integration' are about vertical integration between primary and secondary care (including the VA), it would be good to share experiences of people who'd found work-rounds the purchaser provider split that appears to stand fair square in the way of integration.

#1185 Mark Dancy
Consultant Cardiologist

Seven years ago I proposed the establishment of an ICO comprising secondary and primary care with any savings from admission or referral avoidance being available to improve care in the community. I was branded a traitor by my acute trust employer and the CEO of our PCT reluctantly damned it with faint praise. Was I a deviant?
One of the aspects of service improvement that is never considered is how you make an organisation like the NHS receptive to new ideas. This seems to me equally as important as the other end of the improvement circle, leadership and innovation which receive disproportionate attention.

#1186 Tom Gentry
Policy adviser
Age UK

I'd be interested in seeing how the future Monitor would respond to the deviants you describe above. Circumventing PbR sounds like anathema to competitive interests, or at the very least a stern test of the public interest criteria.

#1187 Nick Pahl
CEO
British Acupuncture Council

I hope deviance and your definition of integration includes health professionals who often work outside the NHS, such as acupuncturists.The British Acupuncture Council is the UK’s largest professional body, with over 3,200 traditional acupuncturists - all our members have degree level training.

#1188 Dr. Fiona MacVane
Health Lecturer
University of Bradford

As an American who has been arguing for a system of socialized medicine in the USA years before I lived here (in the UK) or became a health professional (I have a nursing/midwifery background)I would be VERY wary of following America's lead on anything to do with the organization of health care. The NHS has its problems but it is a far better system than the insurance based systems in the USA and we have far better community services here. Americans I speak to as a midwife are amazed that ALL women receive home visits following childbirth!

#1189 James Bunt
Interim Commercial Director
IMD

Interesting and I agree wholeheartedly with the need for deviance and risk taking. In the current area I am working in there is a projected overspend of around £200m over 5 years. To have a chance of managing this we need to move from organisation to system management. The problem is that this is a risk int arms of PbR and sometimes risk averse interpretations of procurement requirements. Perhaps a good start would be for systems to set and monitor themselves against joint transformation and saving targets i.e. reduce acute beds, create x community beds and save Y. The situation is urgent in so much of the NHS that bold, risk taking and deviant system management is the only option.

#1190 Rodney Knight
Governor
NHS Foundation Trust

My brief experience in the role of Governor of an NHS Trust after a lifetime in the hospital supply industry, leads me to be optimistic that original (preferred to deviant) decision-making is now possible and indeed sought after in the newly-formed Foundation Trusts. With the huge baggage that the NHS carries, it will be a hard road without expressed Gov.t support.

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