Received date: 29 June 2008; Accepted date: 9 October 2008
Practice-based commissioning (PBC) in the UK is intended to improve both the vertical and horizontal integration of health care, in order to avoid escalating costs and enhance population health. Vertical integration involves patient pathways to treat named medical conditions that transcend organisational boundaries and connect communitybased generalists with largely hospital-sited specialists, whereas horizontal integration involves peerbased and cross-sectoral collaboration to improve overall health. Effective mechanisms are now needed to permit ongoing dialogue between the vertical and horizontal dimensions to ensure that medical and nonmedical care are both used to their best advantage. This paper proposes three different models for combining vertical and horizontal integration – each is a hybrid of internationally recognised ideal types of primary care organisation. Leaders of PBC should consider a range of models and apply them in ways that are relevant to the local context. General practitioners, policy makers and others whose job it is to facilitate horizontal and vertical integration must learn to lead such combined approaches to integration if the UK is to avoid the mistakes of the USA in over-medicalising health issues.
integrated healthcare systems, practicebased commissioning, organisation, organisational objectives, primary health care
Practice-based commissioning (PBC) in the UK National Health Service (NHS) is an attempt to plan the best possible health care for entire populations (see Box 1).1 PBC will provide a local planning facility, led by general practitioners (GPs), to complement the systems-wide perspective of primary care trusts (PCTs). Together they will administer NHS funds for the population served.2
In order to plan best care, PBC must enable comprehensive integration of healthcare effort. Vertical integration involves patient pathways to treat named medical conditions, connecting generalists and specialists, whereas horizontal integration involves broadbased collaboration to improve overall health.3 Comprehensive integration includes a good balance of both.
Box 2 summarises the features of these two different types of integration. Broadly speaking, in terms of its data sources and status, vertical integration is the domain of medicine – diseases are researched as discrete entities; linear care pathways consider one disease at a time; discrete treatment packages are costed and evaluated for their anticipated effects; quality assurance emphasises achievement of quantifiable outcome targets. Broadly speaking, horizontal integration is the domain of social sciences – multidisciplinary teams and interagency collaboratives learn, inquire and innovate together; cross-organisational planning leads to a synchrony of effort that creates environments for health; quality assurance emphasisesmechanisms whereby broad groups of stakeholders can examine whole systems of care for their diffuse and unexpected long-term effects and then act for co-ordinated quality improvements.
Specialist treatment for cancer requires vertical integration to ensure that best treatments are given, whereas end-of-life care requires horizontal integration to ensure co-ordinated support from all involved. Treatment of severe mental illness requires vertical integration for generalist and specialist medical practitioners to work together in the best way, whereas horizontal integration is needed to create environments that will develop confident creative citizens. Commissioning must prioritise both dimensions.
GPs are naturally placed to work in the horizontal plane since they have a traditional orientation towards families and communities aswell as individuals. However, targets such as those contained in the NHS Quality Outcomes Framework since 2003, ceaseless structural changes, and the increasingly part-time nature of general practice are making it difficult to sustain this orientation. Furthermore, GPs have been trained in medical science and are concerned with the micro-economics of small enterprises – both of these appeal for their explanatory frameworks to simple and direct assumptions about how a ‘cause’ has an effect (known as the science of positivism).4 GPs consequently have little exposure to social science evidence that broader change is not straightforward:5 future developments cannot be predicted in the simple way that their training will lead them to assume. Instead multiple factors constantly interact and adapt to each other to shape a general trend, as assumed by the science known as constructivism.4 Hidden interconnected factors dominate people’s behaviour, more powerful than the simple explanations people use, as assumed by the science known as critical theory.4 Without a good grounding in these profound and non-linear sciences, PBC is more likely to produce integrated medical systems, rather than integrated health systems.
Combined vertical and horizontal integration: a holy grail
The need to integrate health systems (called ‘comprehensive primary health care’) was agreed at the World Health Organization (WHO) Alma Ata conference of 1978. To achieve this level of integration, healthcare policy must be underpinned by the three principles of participation, equity and intersectoral collaboration.6 However, political and practical obstacles meant that this did not happen.7
In this year of the 30th anniversary of Alma Ata, comprehensive primary health care is again being seriously considered, with a major new WHO declaration scheduled. Consequently healthcare reforms in Europe now commonly emphasise community participation, interprofessional learning and collaboration across the public and independent sectors.8 The national clinical director (England) believes thatPBCcould be a good vehicle to achieve comprehensive primary health care.9 This paper describes models that could help PBC to achieve this.
Meads’ research into ideal types of primary care organisation
Many models of primary care organisation have arisen out of the inspiration of Alma Ata. In the UK, community oriented primary care,10 and ‘Healthy Cities’ are two well-known examples.11 But there has been little research into ideal types of primary care organisation that might help to realise an Alma Ata vision. The concept of ‘ideal type’ is associated with the sociologist Max Weber. It is useful because it stresses those elements that are common to a particular type, providing a ‘unified analytical construct’.12 Toan extent, the various effects of a particular type can be predicted, including their effects on integration. In reality, every organisation is a hybrid of different types, but within these hybrids, ideal types can be discerned. Commissioners can choose to strengthen one or another type to change the overall effect of their existing strategy for integration.
To help make sense of primary care organisation in the 21st century, Meads visited and studied primary care developments in 31 countries that were undergoing major healthcare reforms.13 This led him to examine in detail 24 case studies that illustrated the broader principles of different types. This extensive study presents the most authoritative contemporary examination of different types of organisation of primary care. We summarise Meads’ case studies in Box 3. Meads identified six ideal types of primary care organisation. Below, we synthesise and analyse these ideal types to propose three different models of comprehensive integration. These are not mutually exclusive, and PCTs and PBC may use components of different models in ways that are locally relevant. In order to avoid bias, two authors (PT and KS) analysed Meads’ work in advance of inviting him to join us as a co-author. Meads agreed with our analysis of his work, enhancing the validity of our interpretations.
Three models of comprehensive primary health care
At three different stages of NHS evolution, Meads’ six ideal types naturally group into three pairs, each of which provides a model of combined horizontal and vertical integration. We examine these three models, highlighting options for PBC.
Outreach franchise was the status of general practice immediately after the invention of the NHS in 1948. GPs were independent contractors paid a fee for every patient on their list – but what they did was largely left up to them. The polyclinic bears comparison with the community hospital that was also a feature of the NHS at that time – here specialists rubbed shoulders with GPs, and their patients lay side by side in adjacent beds. Together these provided a model of vertical integration – from general medical practice to specialist medical practice.
Our NHS Our Future signals a re-visitation of the polyclinic idea to enhance vertical integration, as a form of intermediate care where specialists and generalists can meet.14 Professor Lord Darzi, its author, stresses that he uses the term ‘polyclinic’ to mean more than vertical, medical integration. He said in an interview with one of this paper’s authors (PT):15
‘I strongly believe we must get together people from these different health care settings, which are historically built around primary, secondary, and tertiary ... and colleagues doesn’t mean just medical colleagues, it means nursing colleagues ...
... Let me put on record. Polyclinics are not buildings. Polyclinics are my way of describing integrated service provision ...
I think we all need to need to reach that maturity (of leading ‘‘bottom up’’ developments). Not just the Department of Health. Actually all the national organisations need to think about bottom-up.’
The polyclinic model could be adapted to act as a focus for horizontal integration. A polyclinic, whether a large building or an integrated federation of primary care organisations, could house teams of community workers who plan a breadth of community activities, including multicultural events, projects that develop social capital, self-help activities and international exchange. Cross-over planning between the vertical and horizontal functions could lead to one-stop shops that help local people to navigate whole systems of care. Networks for research and clinical excellence could be connected at a ‘polyclinic’, providing a way for universities to channel their local involvement. Recruitment into clinical trials could be led by this unit that would negotiate a fee for this service to fund locally led innovations and audit, in a similar fashion to the approach adopted by Finland’s primary care centres.16
Medical influence will be strong in this first model, and this will inevitably emphasise a medical view of health and disease. That may not be enough to realise the broader aspirations of Alma Ata – that health is everyone’s concern.
Extended general practice and district health systems resemble UK arrangements after the 1990 healthcare reforms when the focus of service delivery changed from the individual GP to the multidisciplinary general practice organisation. Nurses and allied health professionals became employed by NHS ‘community trusts’ that also managed hospitals. They attached their staff to general practices to form extended teams, and developed shared vision and mission through residential team-building workshops.17 An interorganisational local organising team facilitated these workshops and solved political problems.18 This led to enhanced ability to integrate in the horizontal dimension, providing an infrastructure of facilitation and communication to support interdisciplinary innovation.
Multiple variations to the basic model were made in those years, to enable creative interaction between activities in the vertical and horizontal planes.19 In Liverpool, local multidisciplinary facilitation teams helped primary care teams to use action learning and participatory action research to improve quality within geographic areas;20 working with the Healthy City 2000 project they brokered cross-city collaborations for multiple projects that involved general practice teams, specialists, city council, voluntary groups, schools, youth and community groups, trade unions and the media.21 In Sheffield, facilitators used data from GP computers to support local reflection and action for change. In South London a network of multidisciplinary general practices provided local leadership for research, audit, quality improvements and student placements. The Kings Fund (London) led whole-system interventions throughout the UK that enabled synchronised cross-organisational policy between health and social care and the voluntary sector.22
PBC could revitalise these models and from them develop a powerhouse of multidisciplinary learning, innovation and community development at local level. This could provide a focus for ‘bottom-up’ leadership of inquiry and action, to complement the more ‘topdown’ approach that will naturally flow from Model 1.
Managed care and community development agencies are models that change the focus of service delivery from individuals and discrete multidisciplinary primary care teams to whole systems of care. Both claim to be models of comprehensive (whole-system) integration. But they conceptualise the task differently.
The signal difference between managed care and community development agencies is revealed in this quotation from a leader of a Peruvian agency: ‘We see health as a ‘‘citizen’’ not a ‘‘profession’’ issue’ (p.100).13 Managed care uses the term ‘horizontal integration’ to mean treatment in the community of named (medical) conditions.23 A community development agency locates the same term within its framework for participatory democracy, which embraces all things to do with being a healthy society, of which treating diseases is merely a part.
Managed care therefore virtually ignores horizontal integration as we have defined it. Instead it is a sophisticated version of vertical, targeted integration – targeted at a comprehensive range of diseases.
Managed care and community development agencies have quite different strengths and weaknesses. Managed care uses sophisticated ways to track patient movements and costs, but has limited ability to facilitate local learning and co-ordinated action for health. By contrast, community development agencies are effective at enabling local learning and co-ordinated action, but are comparatively slow at producing ‘topdown’ direction, as this quotation reveals:
‘... while lay representations and contributions can be significantly enhanced, so too can the power afforded minorities, vested interests, corrupt cartels and even unrepresentative community factions.’13
However, its ability to fashion a broad consensus and to motivate those involved to ‘give back’ are major strengths. Meads states:
‘it can go a long way towards ensuring that healthcare expenditure and priorities become less of a political burden for hard-pressed governments.’13
Both use networks and systems to connect a diversity of stakeholders. Managed care emphasises the role of these in checking that agreements are understood and adhered to. Community development agencies emphasise their use as a mechanism for co-ordinated collaborative development.
Many advocate the managed care model for the UK.24 Systems to support it have already been developed. The Quality and Outcomes Framework, DrFoster, Choose and Book, Payment by Results – these are data-management systems that help to track patient movements and costs.However, there is little evidence within PBC plans of horizontal integration as it would be defined by community development agencies. If this is not added, as Mexico for example has discovered, undue medicalisation appears inevitable, with all its associated dangers, including excess professional specialisation and regulatory capture, accelerating costs, and reduced population health.25,26
A model that integrates vertical and horizontal activities might include features of both managed care and community development agencies. Meaningful interaction between those who see health as a citizen issue and those who see it as a professional issue is likely to resemble ongoing dialogue, more than hard-wired connection.27 Participatory and wholesystems approaches to research will be needed.28
Both Meads’ original work and our further analysis of it, give commissioners a range of options to plan for comprehensive integration.
PBC aims for combined vertical and horizontal integration, but dominant ways of thinking about how to achieve these, coupled with inadequate training of NHS leaders (not only GPs), are likely to emphasise the vertical dimension. In consequence, PBC is in danger of achieving the opposite of its purpose, replicating the mistakes of North America and the WHO,3 by paying too much attention to the medical aspects of health problems, and insufficient attention to the processes of social cohesion.
Leaders must constantly assert a need for a meaningful balance between the vertical and horizontal dimensions, in pursuit of comprehensive primary health care as envisaged at Alma Ata.3 Further, they must pilot mechanisms that enable vertical and horizontal activities to helpfully mould each other through ongoing whole-system inquiries and action. This will allow the parts (care of specific diseases) and the whole (the health of individuals, communities and healthcare systems) to remain in tune with each other.29 The three models described above provide options to achieve this.
An important take-home lesson fromthis analysis is that combined horizontal and vertical integration can happen in a natural, evolutionary way when those involved have time to think the issues through, and when appropriate theories of change are used. Health service policy must be careful to enable this, and avoid heavy-handed micromanagement that prevents people thinking and acting for themselves. They must remember that the best configuration depends on the local political, cultural and historical context, and enable creative thinking at all levels. Lord Darzi, facilitator of the present NHS reforms, has given a clear commitment to this bottom-up approach. Whether this can be practically realised will depend on the courage and actions of all involved, and not merely his personal determination.
Much is changing in a way that could make very positive improvements in participation, equity and intersectoral collaboration. Already the theory and practice of whole-system learning and change is being introduced into thecommissioning process. The practical work of developing local alliances for polyclinics offers multiple opportunities for multidisciplinary leadership teams to learn how to facilitate broad participation in service developments. It would be fitting, in the year that holds the 30th anniversary of Alma Ata and the 60th anniversary of the NHS, that the UK NHS points the way towards much-needed models of comprehensive integration for health and care.
Support was received from a professor (KS) in receipt of a grant from the American Cancer Society.
Not commissioned; externally peer reviewed.