Category Archives: Primary Care

Driving Integrated Care


A model of integration — ants do it

Two items in the publication, Public Finance (pledge to integrate care and integrated care a long way off), illustrate the frustrating nature of health system reform in the NHS.

Is integrated care hard to do? Are there perverse incentives in the system (things like free-riders and moral hazard, even NIMBY) that work agains effective change in healthcare, and in particular the neverending saga of the NHS? I suggest the problem lies in the methods chosen to solve the problem of integrated care, rather than the value of the goal itself.

  1. Over the years, the NHS has made great strides improving the quality of managers (I used to teach them and co-direct an MBA full of NHS managers) but many appear to be unwilling to speak ‘truth to power’ and take full responsibility for dealing with, in this case, integrated care. Instead, we continue to seek both permission-seeking behaviours in the executive suites of the providers and purchasers (just hate the commissioner language, so gutless), and reluctance to challenge the status quo, perferring the herd mentality.
  2. Foundation trust status has done wonders for improving institutional governance, but operational performance (as we know from Francis) is still uneven. I believe this is in part due to NHS organisations being incredibly weak in terms of their analytical capacity (working with data, modelling etc.) to understand and respond to day to day challenges, which undermines the ability to plan and structure strategic direction in response to changing health dynamics.

Integrated care is not hard to do but does require understanding the patient journey through the system and how best to organise the bits. So where does the NHS go wrong is solving this particular problem?

The models used, and the two articles evidence this are broken. What models does the NHS use? It uses approaches which I liken to ‘team hugs’ and ‘pass the teddy’, feel-good leadership approaches, which do not focus on the outcomes to be achieved, but processes, which may or may not lead to a solution. The result is an overuse of:

  1. “joined up care” rhetoric continues to confuse, yet we still don’t know what it means though it sounds like something we would want; I think it is what we thought we were paying for all along!
  2. “commitments” by those involved become contractual type language of agreement, and which are used to “clarify” what can and cannot be done. But again we see no focus on the problem, but on regulatory and other controls, which if they need clarifying, are perhaps useless if not actual barriers, so why do they exist in the first place? When do we bell this cat?
  3. “ambitous plans”, which is code for more paper which no one will read but which will clutter people’s diaries with meetings about meetings about meetings….
  4. “examples” of what can be done is supposed to demonstrate to people that what they want to do can be done; but if these folk are truly in charge of their organisations and have taken ownership of the problem, would already be probing the possibilities
  5. “pioneer status” is code for people who get to the early money first and get to take one of the examples and try it out by developing a plan which people can talk about, and around we go again.
  6. “top-down” is to be avoided, but is said as a reminder that ‘you are in charge’ just in case you were confused, but given the wider context, you actually aren’t in charge as if you were, we wouldn’t be having this conversation.

The reliance of policy-based tools, though, drives a logic that may not be as flexible as possible to achieve integrated care. If it is such a good idea, what is stopping people?

Integrated care can be driven on the purchasing side by, for instance:

  1. Incentivising providers through bundled payments for whole packages of care that cross institutional boundaries;
  2. Incentivising the emergence of new types of providers to achieve care integration;
  3. Tracking outcomes for processes of care.

Integrated care can be driven on the provider side by, for instance:

  1. Pursuing forms of vertical or horizontal integration that achieves a measure of care integration for specific populations of patients, by avoiding the problems of inter-institutional referrals;
  2. Creating new units of care activity that overcome internal organistional barriers, such as bolting on primary care onto the front-end of the hospital, using step-down units and other alternative provision for different strate of risk;
  3. Ensuring the urgent does not wag the dog and draw resources away from better service stuctures — why does is emergency service so overwhelmed yet the capacity of the system to anticipate and predict so weak?
  4. Bridging skill mix cartels and protected working practices embedded in professional regulation to enable flexible working.
  5. Did I mention working 7 days a week and running at least 18 hours a day? An example of the failure of integrated care is a hospital not discharging a patient on a Friday because [1] the lab doesn’t work late or [2] social services won’t start home care on a Friday afternoon. Integration means doing things when they need doing, not when it is convenient to do them.

It all comes down, in the end, to how you solve a problem. The NHS continues to use methods that have failed in the past, yet these tools continue to be trotted out over and over again.

There are better ways. Email if you want to know more.


Pathways to markets: beyond mere price

The title it a bit obscure, but makes the distinction between people who pay for medicines and those who prescribe them.


There is a pathway for new medicines into markets, and increasingly it is not by marketing to doctors. The pharmaceutical industry to a great extent still sells medicines like the Avon sales person, or the old Fuller brush salesman. It feels almost door to door, and for the pharmaceutical reps, it is doctor’s door to doctor’s door.


But let’s think about this again. A medicine may be priced per-pill, and perhaps that is the essential cost to patients paying cash or with a co-payment. To the payer — the insurance company or government — it is that unit price times the number of patients perhaps taken over 5 or 10 years. I prefer to think of medicines costs in that way as it better captures the longer term population level investments and costs that are involved. Granted there is the selling of the clinical benefits of a new medicine, but increasingly this is an evidence-informed decision making process involving such analyses as health technology assessment. By using my model, the numbers get big and scary really quickly and illustrate the real boundaries of decision making and the adoption of a new medicine.


That means, medicines need to be brought to market as a structured offering, costing perhaps a few hundred million dollars over say 5 years, with associated clinical and outcome benefits to patients and incprporating true value and not just price. In that respect, this will better capture the challenges facing payers, who must weigh out the pros and cons of particular health investments.


In a recent interview by the McKinsey Quarterly, Chip Heath, co-author of a new book on decision-making notes “The typical Fortune 500 manager will run projections from the market data. …  The entrepreneur’s reaction is, “I’m gonna experiment. I’ll find my way into the market as opposed to project my way into it.” The entrepreneurs’ impulse to experiment is right.”


Now, this is quite interesting, and echos Clayton Christensen on the dilemmas of innovation. Running the market numbers does not capture the essential challenges new medicines


English: Example of promotional "freebies...

face and I believe inappropriately positions new medicines as commodity products, rather than what in many cases are true innovations. Mistakenly, companies price new medicines to compete against incumbent products on the market, as though this product had got the price/value equation right. The way forward is to examine the essential cost drivers of payers and linking pricing to these challenges — engage with a payer on the real value and benefits of medicines, taking account of patient and clinical adoption, patient adherence, and longer term value.


So it is time to stop selling and marketing medicines in the old way. Time to move beyond advertising blitz, to true value pricing. One benefit will be smarter discussions between industry and payers. But that will necessitate companies overcoming their own highly fragmented market-facing organisational structures.


Just a word of caution: payers must become more sophisticated buyers of medicines as they will frequently fall into the trap of asking for a discount, rather than negotiating for more value to patients. By the same token, industry may fail to present what today are the essential value drivers of their products. This of course means that in most countries the reimbursement/pricing models are broken or nearly broken, and has not been helped by the sloppy decision-making where austerity is concerned.


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