So many hopes have been built on the expectation that integration is a silver bullet for the woes of the health system, that we really should see it as a golden bullet – far more than a mere silver one.
Well! The reporting of the evaluation of the DH funded integrated care pilots would have you believe that we are doomed! The headlines suggest that patients did not experience greater continuity of care, reduction in emergency admission has not materialised, and there is little, if any, overall financial benefit.
More of a rusty bullet than a golden one!
But the only gold items that rust are fakes – still built of base metal but painted over to make it look like gold.
And we should surely conclude that there is an element of dressing up and pretence about the integrated care pilots. If only we had looked for the evidence before clasping the pyrites to our bosoms.
We know from most industry sectors, that all the case study reviews of transformation teach us that success needs to begin with transformation of the business model. Which of the pilots did this?
We know from our own studies (which will be published in May) that what marks out good leadership of whole systems, demands new characteristics of our leaders: that are currently in short supply amongst the NHS top leaders. Were the leaders of our pilots selected for their fit to these new styles?
We know from the very basics of engineering, that failures occur at boundaries, so our integration design should do three very specific things: reduce the number of boundaries; reduce the risk of failure at boundaries; and, reduce the impact of those failures which do occur at the boundaries. Which of our pilots have used these as design criteria?
We know that for any system to work smoothly and efficiently, we must align the driving forces – i.e. incentives – to make sure that each part of the system is acting in harmony with every other. What dispensations have our pilots been given to devise a new locally fit-for-purpose system of incentives, rather than the conflicting set currently in play?
We know that at times of disruption, attention naturally and easily focuses inwardly to deal with the consequences of change, diverting away from the attention which should be on the relationship with the cared-for. What investments have the pilots made into genuine engagement with and involvement of patients in the redesign, or better still in co-design?
We know that sharing the right, high quality information across the whole system is the only way to reduce some of the risks, build a common purpose and enable all players to feel part of a single solution. Which of the pilots has moved beyond temporary lash-ups between data sets?
Let’s hope that we can now read the small print of the evaluation report, not just the headlines. The small print suggests we’ve got to work harder to get it right. I suggest we just need to work smarter! Integration is not the right answer, especially if most of what we do puts fixes around the current system weaknesses and boundaries. The smart answer lies in understanding how to use the principles of integration to achieve a clear vision of patient centred, seamless care, and then to use that to drive investment in a purpose designed business model, that has all the characteristics to make it work.
Just because we have a pot of gold paint doesn’t turn us into successful alchemists.
David Welbourn 