Within the NHS, there are always some antibodies to the idea that we might learn something about health from the US system, which costs twice as much and delivers poorer outcomes. But the reality is more complex. Almost certainly the poorer US mortality figures are caused by the institutionalised inequity, and when you look to the best of the best, there is clearly much to admire and seek to emulate.
Having spent my early career in engineering and materials science, I understand integration as a necessity to reduce boundary and hand-off effects which in turn are sources of risk and failure. So the current mounting pressure to achieve meaningful integrated processes for care is a great encouragement.
One of the most promising approaches is the Accountable Care Organisation model. It is important to understand that the term “Organisation” refers to the alignment of processes, not a physical entity. I’m hoping that a paper I have co-authored on ACO will appear soon in the BMJ – there is real potential for breakthrough with ACO, simply because the defining characteristic is that it aligns incentives throughout the system, directed towards the desired outcomes.
Well, the Americans have been putting considerable emphasis on the wonder of ACO, since their reform bill recognised its potential. An ACO approach is also one of the few hopes that Christensen has for overcoming inertia of health systems and truly disrupting the health system so that it can tap into the order of magnitude improvements which have happened in almost all other industry sectors but healthcare.
So here is the rub! Some of the thinking about the power of the ACO model comes from looking at the most successful health systems – Mayo clinic, Intermountain, Geisinger, Cleveland Clinic. Federal policy being made after taking a good look around, finding the best and seeking to stimulate an environment in which the very best can be built on and replicated. Sound familiar? Well, it appears that the programme to stimulate such adoption of the best has wrapped the very best in so much centralised bureaucracy, that the best are declining to party. The federal approach appears to be stifling the very stuff which has made it the best!
Let’s hope this is one lesson that Sir David N will choose to learn from the USA! The best are best, because they have worked at it, understood it and given a real sense of ownership to the front line people who make it the best. The very thing which makes it the best, is the very thing which no centralised administration can replicate or, heaven forbid, succeed in imposing.