Lessons from America: achieving integrated health systems

Chris Ham
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 White Paper 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.

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