Martin McShane: Integrated reflections

Martin McShaneSir William Osler advocated the concept of a “quinquennial brain dusting“: which was my justification for taking a week out to visit some integrated care organisations on the West Coast of the USA, with a group from the NHS.

I know we feel challenged in the UK, but the scale and nature of the challenge in the USA made me wonder whether we shouldn’t really count ourselves lucky. The system there is definitely not one to be emulated. International comparators reveal high costs, inequity and, overall, poor outcomes for the population in general. Public spending in the USA covers 30% of the population and represents 8% of GDP. The UK spends 7.8% of GDP on the NHS, for 100% of the population.

I went with a great deal of curiosity and came back believing that the NHS has a far greater chance of addressing the problems enveloping health systems around the world than systems in the USA. That said, there were things to be learnt. The organisations we visited have attributes that are sympathetic to the values and principles of the NHS with approaches that could be adopted or adapted, to good effect, to amplify or unlock the potential of the NHS. They are also doing things which are new and exciting for them, yet well established in the UK and undervalued – I will come back to primary care later.

The first place we visited was Kaiser Permanente. A lot has been written about it but our seminar with their Care Management Institute (CMI) added insight. The CMI’s aim is “to make the right thing easy to do.” It sits between the purchaser and provider, working with the Care Experience Group (patient voice) to create and support implementation of innovative, evidence based programmes. It reminded me of a blend of NICE and the NHS Institute. Use of an electronic medical record and care bundles, coupled with a systematic approach to patient flow supports both individual and population care. However, they have concerns about 100% adherence to protocols as they believe that is detrimental to patient care. They don’t want “cookie cutter” medicine but believe protocols, implemented intelligently, release time for clinicians to spend on complex cases.

It seemed to me that Kaiser was an integrated system, with medical groups tightly aligned within it by the system rules and incentives. The hospitals, primary care, and purchaser have a mutually exclusive compact and shared revenue model supported by clinical integration. An important attribute, I sensed, was the culture. There is a significant peer culture and physicians are carefully vetted. If they don’t fit then they leave. Although management is appointed, physician leaders are elected. The information on individual physician performance is much richer than that released to the public and covers multiple domains, including patient experience, efficiency, and productivity. The information is used to look at how both individuals and populations are treated. There is a significant investment in training: use of IT, communication skills, and a peer to peer program. The medical groups are self governing with devolved accountability. Physician leadership is seen as integral to success.

Critically they see the role of the primary care physician (PCP) as vital. Without good primary care, things, in their experience, have gone bad, fast. They have embarked on moving towards a system embracing continuity of care, creating a panel of patients who have a “relationship” with a named PCP. To deliver this they are investing in reducing panel size to somewhere between 1.7 and 2.5k.

So, at its heart, Kaiser has identified a model of primary care which would be very familiar to a UK general practitioner. The culture, however, is radically different and this is a theme we came across elsewhere. If there was one major lesson I took away from our day with Kaiser it is that paying attention to physician leadership and culture is imperative to make integrated care work. But is it a culture which GPs here would be willing to embrace?

…to be continued.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.