Intended for healthcare professionals

Rapid response to:

Analysis

Clinically integrated systems: the future of NHS reform in England?

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d905 (Published 28 March 2011) Cite this as: BMJ 2011;342:d905

Rapid Response:

Yes, but not on the commissioning platform

Chris Ham and colleagues are partly right that there is no inherent
contradiction between pursuing competition and integration simultaneously
and I agree with their concluding remark about focus on medical groups of
GPs and specialists. (1). Indeed we could look to the airline industry to
give us a clue on how this could be achieved. There is considerable choice
and competition between different airlines, each of which manages the full
end to end process from ticket booking, check in to safe disembarkation.
Medical Groups around clinical specialties could be like the airlines with
GPs and hospital clinicians working together to develop and deliver the
full pathway, and hospitals providing the necessary infrastructure just as
airports do by providing buildings/waiting areas/security/baggage handling
etc. But I do not believe that this either ensures comprehensive coverage
or is feasible given the way the NHS is organised at present.

The difficulty with the current debate is that we are stuck in the
paradigm of commissioning/competition/choice, and are trying to find
reasons and workarounds to justify this. We keep pursuing the panacea of
purchasing and markets and which has failed since its introduction in
Working for Patients by the Thatcher Government. I do not see how the much
needed integrated model demonstrated by Torbay or the Veterans Health
Administration can be built on the general practice commissioning
platform. Yes, commissioning may make some difference in a small
proportion of the comprehensive health care needed by the population and
yes, it could work in some geographical areas but will it work for all
services and in all places? I doubt it, and hence any small gains from
commissioning have to give way to the bigger needs of integration. Time to
stop justifying commissioning and time to adopt integration as the new
single organising principle for the NHS?

rajan.madhok@btinternet.com

The views expressed are personal.

1. Ham C, Dixon J, Chantler C. Clinically integrated systems: the
future of NHS reform in England. BMJ 2011; 342: d905

Competing interests: No competing interests

02 April 2011
Rajan Madhok
Medical Director
NHS Manchester