Following our visit to Kaiser Permanente, we travelled north to Seattle and visited the Virginia Mason hospital and Group Health. Linked but distinct, the relationship between the two provided a contrast to Kaiser Permanente – though, as organisations seeking integrated care, there were common themes.

We spent a day at Group Health and yet again I was struck by their emphasis and focus on Primary Care as the central driving force for delivering value: high quality care associated with (relatively, for the USA) lower costs. The term they use for this concept is Medical Home. As at Kaiser, there was a strong culture of medical leadership; the primary care physician is valued as a leader and integrator of care. Their Primary Care Centre (Medical Home) managers all had a clinical background, as well.

Group Health had slimmed down their primary care facilities in the 1990s as they thought they looked ‘unproductive’. Over the next three years they lost $80million. It took a decade to rebuild.

What was very striking was the clear link between the strategic goals of the organisation and the teams delivering care. Group Health has adopted Lean principles. Everywhere we went in the organisation, from the executive team’s meeting room, to the central administration area in the Primary Care Centre, one could see and track the connection and ownership of the process measures and outcomes which are seen as essential to deliver the vision and ambition of the organisation. Data, posters, A3 problem solving, made visual the concerted effort being made to improve and deliver. This is supported by a process of strategic deployment which relies on input and feedback from all the staff. This culture isn’t easy to imbue across a whole organisation and it has taken years, not months, to see it adopted.

What are they trying to do? Reduce emergency admissions, develop better ways to address chronic diseases and frailty, improve health, maintain quality with lower costs; these are all familiar issues. What felt different was the collective ownership, insight and ambition to do it across the whole organisation.

Although Group Health does not own hospitals it does have long term partnerships with hospitals in the region; one being Virginia Mason. Founded by 8 physicians the group has developed the Virginia Mason Production System. Basically, it is the application of Lean principles. Once again it is supported by a strong culture of clinical leadership. As one clinical leader put it to us, “we remove doctors who are not aligned to the commonwealth of the community”. There was also one comment he made which resonated and has come back to mind several times since:

“Structure is necessary and important – hierarchalism isn’t.” I know hierarchalism isn’t a proper word but it conveys a meaning which, as we left Seattle, resonated with me. I think it is this: the centre has an important role but it needs to understand its role is not to tell people how to do things but to make it easy for people to do the right thing.

Is that a role the NHS Commissioning Board, Monitor and the CQC will be embracing?

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.