Thursday, 16 December 2010

Squaring the circle

The English health reforms present a range of challenges. Currently there is much more focus on improving quality while budgets are reducing and both Primary Care Trusts and Strategic Health Authorities are in transition to general practice lead commissioning. One of the other central planks of the coalition government’s proposals is to extend choice and competition and to reduce reliance on targets and performance management. These proposals are designed to put patients at the centre of the NHS and improve outcomes.

But alongside the emphasis on choice and competition there’s been increasing interest in integrated care. The belief is that more integrated care will achieve more personal, responsive care and better health outcomes for a local population. On the face of it, integration and any willing provider make strange bedfellows. Integrated care could act as a barrier to choice and competition if it were to entail establishment of organisations that become monopoly providers of care in their areas. Can this circle be squared? An alternative view to the monopoly provider argument is that integrated care organisations could be at the vanguard of the disruptive innovation needed to improve performance, especially if there is competition among integrated care organisations. Taking this view, there is no inherent contradiction between integration and competition provided that patients are able to exercise choice either within or between integrated care organisations.

Chris Ham and Natasha Curry from the Kings Fund make these points in “Clinical and Service Integration, the Route to Improved Outcomes” to emphasise the need for a more nuanced debate about the direction of reform that recognises the possibility of integration and competition both having a part to play in improving performance. To simulate that debate Natasha and Chris have drawn together the evidence on the performance of the integrated systems and the many ways in which integrated care can be achieved. They argue for greater clarity on the meaning of such terms as integration, integrated care and integrated care organisation. These terms are often used synonymously but have many different meanings. Clinical and service integration summarises the evidence for whole system approaches such as Kaiser Permanente in the USA, examples of chronic care models for particular groups of patients such as the elderly in Europe and North America or disease specific managed clinical networks in Germany, Sweden and the United Kingdom. Finally, they make the point that for the individual patient and to improve population outcomes, co-ordination of care is essential. They found that the adoption of multiple strategies to achieve this goal were more successful than those using single strategies alone. Concluding that improved communications between providers and the provision of support for patients maximises the chance of improving quality and outcomes.

What role might information on providers play in this drive to improve quality? Martin Marshall and Vin McLoughlin from the Health Foundation examined this question in a recent British Medical Journal analysis “How do patients use information on health providers?” BMJ 2010; 341: c5272. They cite the recent literature that shows the public want information about performance to be published but do not look at it and that it has had limited impact on improving quality. They argue that decision making in healthcare is more complex and at first sight less rational than, for instance, getting a good deal on your next car or holiday. They point to the various social processes in addition to the cognitive ones involved in how individuals make trade-offs to reach decisions. These might seem irrational to the outside observer but yet have strong internal logic. Data that is important to clinicians and commissioners is often perceived differently by patients.

So providing useful information to patients is much more of a challenge than we have traditionally thought. This is not a good reason not to include the relevance and accessibility of performance data or not to provide the information at all. On the contrary, as Martin and Vin state not only should it be seen as “a good thing on its own but may also start to engage a large number of people in the future”. We need to make information more appealing, to develop patients and the public’s health literacy and to be aware of the different health beliefs that exist in our population. Co-producing health with patients brings integration, competition and information together for the goals of improving both the health and the experience and outcomes of care.