Martin McShane: Integrated reflections concluded

Martin McShaneHere is my third and final blog on the USA trip: After Seattle’s integrated care organisations, we visited CalPERS. They fund $6.7bn worth of healthcare for 1.3 million people (roughly twice what we have per person in Lincolnshire). They see themselves as “active” purchasers: managing the market to reduce costs. About two thirds of their members are in capitated plans (for instance Kaiser) whilst the remainder are in a PPO plan (Preferred Provider Organisation). Simple examples of their interventions were to remove co-pay from preventative care for members, to have fiscal and chronic disease management targets and to set a tariff for knee replacement–it all felt familiar. What wasn’t was their analysis by price for knee replacement. It revealed a staggering variation from $15k to $120k. With 46 hospitals they agreed a tariff of $30k but patients could choose to use hospitals that refused the tariff – so long as they paid the difference. It made me think why a tariff for planned procedures may not be such a bad idea.

It was clear from listening to the executives at CalPERS that they faced similar challenges to us. For example, they have just as many, if not more, problems with collating, analysing, and using data because of regulation and legislation.

The big new initiative in the USA is accountable care; visits to the Blue Shield Foundation and the Centre for Health Policy at Stanford gave us an insight into the challenges which health care reform faces in the USA. Accountable care has the aim of increasing access to insurance, improving quality, and reducing costs. Yet again, at its heart, is primary care. Whether it will deliver the three aims intended is open to debate – in a society that retains bad memories from managed care and a social construct that is very different to the UK.

Returning home I felt reinvigorated. I was proud to work for a health system that did not need to concern itself whether individuals could afford the care they needed. I felt excited by the conviction that, for integrated care to work, it needs to be driven by primary care.

What are the three key lessons I brought back?

  • The importance of primary care
  • The importance of physicians embracing leadership
  • The use of lean principles to support and create the right culture.

Applying those lessons to the NHS won’t be easy.

Primary care, because of its independent contractor status, is mistrusted by many parts of the system.

Some places in the NHS have made lean principles work; even in general practice. Putting this at the heart of the system, as has been proposed, would, however, require a fundamental change in culture at the centre of the NHS.

The medical profession has, in the past, taken a somewhat disdainful attitude to leadership and management of the health system. The Royal Colleges, at long last, have recognised this and established a Faculty of Medical Leadership and Management. Maybe one of the measures of change will be to see its membership grow and the faculty prosper.

Maybe another change will be if the NHS commissioning board does set a new tone and forges a new type of relationship with the emergent Clinical Commissioning Groups that supports truly integrated care, trusting and investing in primary care to take the lead.

It is a big ask – but what is the alternative?

Carry on doing what we’ve always done and expecting something different?

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.