I’m only a couple of months into my year in the USA.
Breakfast with Lansley. Lunch with Berwick. A chance meeting with Obama (Michelle, not Barack). And dinners with more top-rate health care academics, analysts and policy-makers from around the world than would have seemed possible just a few short weeks ago.
With this has come slides – lots of slides. Slides showing how bad things are here. Slides showing how good things are there. Slides showing how Japan is doing its best to make everyone look average, and slides showing how India plans to break the mould in eye-popping fashion.
Meanwhile, political point-scoring, polarised debate and an air of surreality encircle health care reform. Here, and in the UK. From Capitol Hill to SW1, from the Supreme Court to the Health Select Committee, from Fox News to HSJ, from the New York Times to the Daily Telegraph, from Twitter to, well, Twitter. Myriad opinion.
For the NHS going forward, it is imperative that this growing tension, between a system of economic regulation and the coordination of effort aimed at health improvement, is carefully addressed
But, there is a limit to pleasant breakfasts, long lunches and fine dinners. And slides are good – but please, not too many slides. Opining, meanwhile, should have a shelf life – a short one.
There really does come a point when, as regularly exclaimed on the streets of Philadelphia that I currently call home, you have to JFDI. Admittedly, there are problems facing those who are ready for the JFDI approach to achieving positive change in health care.
For those prepared to take the leap, it can be a lonely place. Failure likely brings no personal rewards, not forgetting that failure can be hugely important for wider learning in the system. Equally, where success is apparent, how does innovation – a new approach to quality improvement, better cost containment, effective multidisciplinary working and so on – get noticed, get evaluated and, ultimately, get diffused to deliver the same or greater benefits elsewhere?
Moreover, those ready to JFDI often report insurmountable barriers to progress or, at the very least, a set of frustrating hurdles, that arise from the complex regulatory and legal frameworks within which they must operate. It is this problem I am currently focused on. And what I will no doubt blog about over the coming months.
Central to this quandary, is the much-discussed relationship between integration and competition. Policy makers, health care leaders and commentators on either side of the Atlantic are voicing shared anxieties that legal and regulatory obligations concerning competition will stifle efforts aimed at better integration of care.
Such obligations, it is proposed, will create an unwelcome obstacle to achieving desired improvements in care delivery and to ‘bending the cost curve’ (US) aka ’meeting the Nicholson challenge’ (UK).
These tensions have a long history in the US. Interplay between the health care sector and the US agencies responsible for competition policy – the Department of Justice and Federal Trade Commission – is nothing new, dating back to the 1980s.
Today, as the accountable care organisation (ACO) movement gathers pace in the US as a result of the Obama health reforms, concerns of this nature have been very publically reinvigorated. Once again, the fear is that more integrated models of health care delivery will fall foul of restrictive regulations and the strictures of competition law.
In a similar vein, discussion of integrated care in the NHS over the past decade has often focused as much on perceived barriers to achieving ‘integration’ as it has on actually trying to better define and operationalise the concept. Recent years have seen no change in this respect. Hours and inches of debate and analysis have been characterised by a particular fascination with issues raised by the increasing role of choice and competition in the NHS, and the potential impact this may have on initiatives focused on integrating health (and social) care services.
Now, with the Health Bill advocating both greater integration and competition – best captured in Monitor’s future role of both enabling integration and protecting against anti-competitive behaviour – the tensions are writ large. At the same time, it is ironic that ACOs are now also entering the lexicon of NHS reform, for better or for worse. For the NHS going forward, it is imperative that this growing tension, between a system of economic regulation and the coordination of effort aimed at health improvement, is carefully addressed.
This is where lessons can be learned from the US (as hard as this may be for some to believe). From mistakes made, to progress achieved, what emerges from the fog of US experience are a number of principles, technical points and simple conversations.
These might usefully inform work to foster an NHS that moves further down the road toward a sustainable future, delivering high quality care for its patients, alongside and within the bounds of complex regulation and law.
Meanwhile, for those of you who think you’re really onto something that is going to make a meaningful, positive difference – the streets of Philadelphia have four little letters...
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