17th November 2011

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Deja vu?  

News and Comment from Roy Lilley
PPA 'Columnist of the Year' - Finalist


I've sort of done integration to death.  If we really mean 'integration' then the King's Fund and the Nuffield can NuffKing themselves to death but they won't come up with a solution to the problem.


The problem being that the NHS is not integrated, it is fragmented and the direction of policy (to create a mixed economy on the supply-side of healthcare) is going to make it impossible.  They can come up with cosy 'work-togethers' but they won't fix integration like you can't carry water in a sieve.


Apple is integrated.  Microsoft is not.  You know all that.


I detect that LaLa knows this.  I suspect he realises pulling some of the legs off a spider isn't going to make it win the three legged race.  I think he knows the damage he's done.


That is why I was not surprised when an insider told me that during his recent trip to the USA LaLa was taken with the idea of accountable care organisations.


ACOs are new hybrid organisations that are appearing in the US. They are provider-led organisations that are grounded, fundamentally, in primary care.  They are starting to be popular in the US as they are tipping the balance of power away from the fat-cat hosptials that are hoovering up all the money.  They are quasi-purchasers part providers that are responsible for developing care pathways across the boundaries of providers .  Their payments are linked to quality improvements and reduction in costs.


They are also subject to progressively more sophisticated performance measurements, to support improvement and provide confidence that savings are achieved through improvements in care.   They are a very controvercial idea for the US health market that is dominated by the big health management organsations and insurer 'payers'.


They are forcing an integration in a care system that is fragmented, where the GP, or primary care phycisian, is not the gate keeper and the Obama healthcare change programme is running into all sorts of problems; mainly about control and money.


There are resonances for us.


FTs are designed to hoover up as much care as they can suck in.  It is true they face penalties and it is true that in some cases, any volumes over 2008 activity levels are paid at 30% of trariff.  This is designed to slow them down.  In fact it has the revesre effect, forcing them to new heights of efficiency to compensate for the hit on the tariff.


Primary care should be shouldering more of the treatment load.  Not because they are likely to be any better at it and it is only probable that they can sustain cost-per-treatment savings in the long run.  No, the real reason it is a lot more convenient for the customer.  However, there is a flaw in this hope; most primary care premisses are stuffed to the gunnels already, and inlikely to have the room for much more expansion.


Community services, the bridge between the two, it rickety.  They are mostly working on sweet-heart block contracts based on activity five years ago and with little room for expansion.  When they run out all hell will break loose.


At first sight an ACO, with the partner organisations pooling resource, focussed around the care pathway, targeted on quality and cost makes a lot of sense.


I was speaking to an American healthcare policy wonk.  He said he thought they were a good idea.  He was surprised that I was surprised.  


He said they were based on a British idea; Primary Care Trusts. Deja vu?


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