Editor's blog Friday 8 October 2010: Integrating care – what Leutz can teach Lansley

Health Service Journal editor Alastair McLellan tweets that Health Secretary Andrew Lansley told an event at his party conference this week, “patient choice drives integration of care”.

Initially, this looks like an odd statement. I think it probably is an odd statement.

The first thing it brought to mind was Walter Leutz’s 1999 article ‘Five laws for integrating medical and social services: lessons from the United States and the United Kingdom’ (Milbank Quarterly, 77, pp 77–110).

Leutz proposed five laws of the integration of health and social care (and later added a sixth, in the Journal of Integrated Care). They are good laws, and so let’s consider White Paper reform proposals in their light.


1. You can integrate some of the services all of the time, all of the services some of the time, but you can’t integrate all of the services all of the time
A nice reworking of Abraham Lincoln’s dictum about fooling people, this is to some extent a statement of the obvious. The White Paper places all its faith in the three Cs of choice, commissioning and competition.

If we are talking about services – provision - then the ‘any willing provider’ model, together with protected funding for the NHS, is designed to actively promote a competitive market with oversupply. It is questionable whether that will drive integration of care. Market proponents will argue that competition among providers and patient choice drives out bad quality – although the recent Kings Fund’s research into choice suggests that it has not yet “acted as a lever to improve quality”.

If we are talking about the commissioning side, so little detail on consortia has been set out that it is impossible to discern whether they will be competitive with one another – or indeed with the acute sector in terms of commissioning their constituent members’ self-provided services.

It is however wholly clear that people will have a choice of commissioner via their choice of GP. That of course assumes practice lists will be open. If lists all snap (or stay) shut, this will of course be stymied. Therefore this will be core to the contract renegotiation with the BMA.

2. Integration costs before it pays
Oh yes indeed. Just as today’s Guardianreveals that in the short—to-medium term, the quango cull will cost a significant sum more than it saves, the architecture of patient choice – not just of which hospital but of which GP, which clinical team in secondary care etc – will be expensive to create.

It will cost money to establish good data on which choice can be based; good information campaigns to explain it all (current patient choice ranks low in public awareness); and it will cost management and IT time and effort to ensure that the people don’t get lost at the handover points. Which is what always happens.

And in the brave new world of the White Paper, with greater patient choice and more plurality of willing providers, there will be more handover points.

Meanwhile, there is the small matter of making £5 billion a year on cost savings for the next four financial years. Which according to HSJ, is not going terribly well so far.

3. Your integration is my fragmentation
‘You there! NHS manager chappie! You’re going to make these changes to the system, and we’re going to make lots and lots of your jobs redundant. Chin up! We’re all in it together you know – in the National Interest”.

You get the point.

More broadly, it is fair to say that there are some very bad services indeed in the NHS. The question is not whether these should be better – of course they should. The serious questions would be ‘is there a geographically plausible alternative option that would allow us to fragment this service to the point of closure?’, and ‘if we are decanting services out of hospitals (a good idea), where are we going to provide them?’ Primary care is not full of unused real estate – at all.


4. You can’t integrate a square peg into a round hole
That isn’t to say you can’t try to do so, but there are reasons for many of the ways the NHS is as it is. The desire to abolish the intermediate management tier of SHAs is not a new one. In practice, it’s never worked. The intermediate tier always reinvents itself. After a nuclear war, all that’s left will be cockroaches, Bruce Forsyth and the intermediate NHS management tier.


5. S/he who integrates calls the tune
A Thing That Is Not Surprising, writ large. The problem is likely to be this: the NHS has concentrated power and management capacity in the acute sector since forever - and particularly in foundation trusts since 2003.

PCTs were by and large not able to drive significant changes in use of expensive secondary care; nor to provide new community services to get people out of acute care quickly or avoid the need arising. That was the failure of commissioning by the people who held the money, and it was the failure to create integrated – or diverting – services.

Here is a conundrum: Mr Lansley is apparently serious about giving away power. He regards power to be a zero-sum game, and if the Independent Commissioning Board and thre GP commissioning consortia are to have more of it, he must have less.

The problem arises because what we know of the new system’s architecture replaces the Secretary of State with the chief executive of the Independent Commissioning Board.

It also arises because we have too little detail on how consortia will work and what their management allowance (which will determine staffing) will be. To some extent I am sure Mr Lansley is wholly sincere in not wanting to dictate an organisational form from on high. The one-size-fits-all mantra runs deep in the bowels of Richmond House (and works nicely for a former communist such as Sir David Nicholson).

If we take Mr Lansley at his words, then patients will drive integration through their choices. It would genuinely be nice. There are quite a few obstacles.

The medical profession’s extant interest springs quickly to mind. Every profession has interests. The medical profession, via the British Medical Association, has done very well by its interests: good on them.

Less good on them is the ducking of assessment and revalidation. There is vanishingly scant evidence either that doctors like regulating one another, or that they are effective and efficient at doing so.

“MTAS / MMC” they will quite rightly respond. There is scant anwer to such dire incompetence of the system (though MTAS was partly intentional, I suspect, to ensure that every hospital including the unfashionable and far-away got a full complement of consultants).

Another obstacle is the apparent refusal of many patients to choose anywhere other than their local provider. The sociology behind this apparent trend deserves research.

But if patient choice is not even driving significant change now, it is hard to see how it will drive integration of care.


6. All integration is local
The £20 billion question the NHS has long faced – how do you make a national service locally responsive and appropriate?

Services are generally local – most of the NHS’s business is the unglamorous care of long-term conditions. Elective and emergence acute care makes good TV programmes (sometimes), but are not the core business of healthcare. The management of chronic disease is that core business – as Leutz and colleagues from Kaiser write in this article about a Kaiser project in the USA.

Patient choice in long-term conditions could do fabulous things – develop patient expertise and self-management. It could probably save a fortune. It has been a stated priority for some time in the NHS – and somehow, it is still not universally happening.

The big unanswered question from the White Paper is how much local freedom will consortia be allowed? The Independent Commissioning Board is, with NICE, to define the core treatments the consortia must commission. It is to design the structure of tariff; design model contracts for commissioners; set standards for the quality of NHS commissioninig and procurement; provide information on commissioner performance. It must also allocate and account for NHS resource.

How is the ICB not the new Secretary of State for Health?

More to the point, there is no way it can be the light and lean organisation Mr Lansley reputedly wants it to be.