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Editor's blog Friday 19 November: Mark Britnell's presentation to the NHS Alliance conference

Mark Britnell

Power in the new system – the power to integrate

Power can be used to fossilise relationships and indeed healthcare delivery in mid-20th century, or used to develop relationships in much more generous integrated way. It’s time to use power to integrate.

The finest characteristic of the NHS is the general practice registered list mapping 99.7% of population to a GP. Most countries in the world would pay for that.

To get the right thrust of reforms, we should  talk less about means and focus much more on ends. If we end up with 500 cottage-sized industries, we’ll fossilise 20th-century medicine and lose opportunity to deal with the greatest epidemic facing medicine.

The power of £80 billion should be used to integrate

The most important delivery vehicle will be what you build with social care. The NHS is uniquely placed globally to make this a success. Current debates are about restructuring; not about vision and ambition. I absolutely fundamentally believe in GP commissioning.

Some could argue (and I might be to blame) that most reforms levers of the past decade focus on secondary care, and now the levers - which I think need to be remantled; not dismantled – to encourage secondary care clinicians. I think the time is now come for looking at different employment models like partnerships or chambers. And it’s be a shame to fossilise separation of primary and secondary care.

You have great power; how you use it will clarify the NHS for next two decades. You are getting more responsibility and accountability.

Sustainable change has to be driven form patient point of view. Anything else will be either a fad or out of steam in 2-3 years. You advocate for patients. The choice of GP you sign up with is one of the most important in your life.

The new system will have to align personal incentives with organisational responsibility. and high-performing systems all have this desire to be ambitious and pursue restless improvement; they use IT to personalise care; they blur boundaries of primary and secondary care and social care; they use nformation and technological solutions. All that is going to be of paramount importance in the next 3-4 years.

KPMG did some work in a big Northern city in excess of 1 million, which found that clinically-based decision-making will deliver over £200 million efficiencies by 2013-14 for a £1 bn health economy, through using better integration and pathway redesign. So we can produce 20% efficiency gains, but more strikingly, the time to benefit is 2 if not 3 years.

The issue about healthcare integration becomes the most important for the next 10 years, and I’m not sure we yet have all the policy and structure levers to ensure we reshape services.

We’ve done a piece of work on better integration; a study with Economist Intelligence Unit of CEOs on the benefits of integration.  61% said integration led to better outcomes, and also better disease outcomes and reduced cost.

Research on integration is often bedevilled by a lack of clarity on words to be used. People often use the ‘i’ word to mean a variety of things, which is not wrong, but you need the right form  of integration for the right task.

For functional integration, I think the future is 15-20 giant national players providing services like HR, technology, data, contract negotiation and monitoring, holding providers to account. To ensure that the patient journey is good, we need clinical and service integration. Too often, integration in the NHS is just redisorganisation as we can’t think of anything else to do.

Clever GPs and clinical commissioners will think of outcomes not means, employ those within and outside of the NHS to ensure means professional

In the US, the Obama administration is introducing the accountable care organisation. The UK is leading the world in this area of health policy thought; let’s hope we do in delivery. In the US, Geisinger offers a different model, where hospitals employ GPs at $120,000 a year.

You have lot of power: please use it wisely, and organise accordingly to build 21st century healthcare. If you don’t want to do this, the hospitals will do it for you. Merry Christmas!