1. The Harkness Journey

2. Why Harkness?
• Had been on 3 study trips to see US
healthcare:
– 2001 ODP network (with Pam and Steve Pashley)
– 2003/4 DH fact finding Kaiser and Evercare (with
Steve Dunn)
– 2007 Northern Ireland to Kaiser (with Tim Kelsey)
These experiences left me very positively
predisposed to further ‘study’ in the US!

3. Journey
• Was working in Trafford with set of physician
and management colleagues to develop ‘first
principles’ model for integrated care and
became involved with Nuffield policy work
• Fellowship based at Stanford with Alan Garber
• Now working as Senior Adviser on Health
Reform for Republic of Ireland
• Cannot be recommended highly enough -
deserves it’s ‘life changing’ epithet

4. Highlights
• You mean I get to meet these people:
Karen Davis, Mayor Bloomberg, Alan Garber, Don Berwick, Brent
James, Elliot Fisher, Larry Casalino, Alain Enthoven, George
Clooney, Julian Legrande, Karen Davis, Ken Kizer, Don Light, Jay
Crossen, Karl Ulrich – extraordinary fellow fellows!
Being published…
Light, D and Connor, M ‘Reflections on commissioning and the English coalition
government NHS reforms’ Social Science & Medicine, 2011, vol. 72, issue 6, pages
821-822
Connor, M ‘Local innovation can’t be driven from the top down’ British Medical
Journal, 2011;343:d5719 doi: 10.1136/bmj.d5719
Integrated Delivery Systems and lessons for health reform in England (prepped for
submission)

5. The research

6. There is much more talk about systems (and
integration) than clarity about what we mean…

7. Methodology
Research question: Can we be more explicit about step 2?
Systems selected following key informant interviews and literature review:
Marshfield Clinic, Veteran’s Health Administration, Kaiser Permanente,
Intermountain Healthcare
All established and mature integrated delivery systems, albeit with very
different ‘natural histories’
Semi-structured interviews, publically available and private literature, site
visits
Work involved c. 37 interviews undertaken at four site visits and meetings
with system leaders

8. Marshfield Clinic

9. Map of Marshfield Clinic service area (Wisconsin)

10. Natural histories
Marshfield
Original group started in 1916 with 6 physicians
Grew organically until the mid-70s when it underwent a rapid expansion through acquiring
an extensive network of community based primary care and small group practices (a ‘turn’
to primary care)
Very long-standing commitment to EHR with some health records going back to the 1970s
and a genetic engineering research facility with 20,000 patients registered with genetic
information, blood samples and electronic histories (can trace Germanic family lines…)
The clinic is nationally recognised for its ICT and managed to convert its entire clinical
system into a paperless operation in three years from 2004 – 2007 and every physician now
practices on a laptop – as I directly observed
Achieved by far the highest level of savings (>$30m) of any of the 10 PGP demo sites from
2005 – 2010, which it is now investing in getting NCQA accreditation for all its primary care
sites as medical homes

11. The VHA

12. Map of VHA VISNs

13. Natural histories
The VHA
Established after WWI to provide care for veterans suffering as a result of their military
service (though some accounts trace its roots to the first federal military veterans hospital
in Pittsburgh in 1778)
Its beneficiaries expanded massively after WWII, Korea and Vietnam and a series of high-
profile quality problems led to a major loss of confidence in the 1980s and 1990s
Underwent a major re-engineering and transformational change from 1995 – 1999 under
the leadership of Ken Kizer (not least based on universal primary care)
RAND study (04) found VHA outperformed the rest of US healthcare on 294 measures of
quality… CBO (09) said care ‘compared favourably’ with that given by non-VHA providers
Especially noted for its extraordinary VistA open-source EMR and very strong relationships
with academic centres for research and physician training

14. Kaiser Permanente

15. Map of Kaiser Permanente facility locations

16. Natural histories
Kaiser Permanente
Founded in 1942 by Henry Kaiser and Sidney Garfield from a history of industrial health
management associated with the Colorado River Aquaduct, the Grand Coulee Dam and
WWII shipbuilding.
From its inception was closely associated with a primary care model – developed to offer
efficient care for workers and their families
Lost $770m in failed attempt to write its own IT system with IBM, which led to a new
approach, ultimately with Epic Systems, to implement HealthConnect – ‘the largest civilian
electronic medical record system’, implemented at a cost of $6bn, or c $500k per physician
It has a tri-partite structure of KP Hospitals, the Permanente Medical Group(s) and the KP
health plan, seen as ‘three legs of a stool’ and fully aligned strategically
Scores highly in State and national quality reports – in 2009 becoming the first HMO to get
4 out of 4 stars in the ‘Meeting National Standards of Care’ category

17. Intermountain Healthcare

18. Map of Intermountain Healthcare facility locations

19. Natural histories
Intermountain Healthcare
Initially formed as the entity for the LDS to spin out its hospitals in the mid-70s
Experienced significant ‘mission conflict’ (Brent James’ term) in implementing cost control
strategies in the 80s and a failed venture into the insurance market
Formed its medical group only in 1995 and its differentiation into a systematically managed,
high-quality system dates from this time – 75% primary care at inception
Like Marshfield, has a long history of EHR going back to the 70s and is presently engaged in
a massive renewal of its system, partnering with GE, into which it is incorporating
standardised workflow associated with agreed models of care
Only system to be ranked No 1 out of 600 5 times in the Modern Healthcare/ Verispan
annual rankings (in 2000, 03, 04 and 05… it came second in 01, 06 and 07) (wonder what
happened in 2002)
Has developed and runs the world-class Advanced Training Programme for clinicians in
quality improvement

20. 5 ‘structural similarities’ of the IDSs
studies
1) Mapping of population to primary care physician
2) Systematic accountability for PCPs as providers
in the context of integrated system
3) Shared governance (PCPs and specialists in the
same business)
4) Multi-specialty physician group controls/shapes
hospital services/ contract using make or buy
5) Physician-led commitment to information
systems

21. Can we discern a ‘strong archetype’?
Overall physician control
No ‘skin in the
game’ for GPs
GP or consultants
registered thus left to
list GPs only formally management
accountable for cadre
primary care piece
Specialist teams
Hospital services
Primary Care
Population
Shared Virtual or
Mapped to governance actual
with control of
Commissioning,
compettion and
choice make
MSMGP difficult or
impossible
Domain defined by
Strategic
Heath
Information
Teams
EHR (Electronic)

22. CONCLUSION
First, by establishing Clinical Commissioning Groups in the same evolutionary
line as PCGs and PCTs, the reforms persist in placing GP leaders on one side as
‘purchasers’ with the hospitals on the other side as ‘providers’. This
oppositional structure is likely to end up in the same space as its predecessors –
with weak control and little in the way of integrated working.
Second, the particular emphasis on ‘Any willing provider’ and ‘patient choice’
means that it is difficult to conceive how GPs and consultants could form
anything like the multi-specialty physician group entity that lies at the heart of
the successful integrated systems in the US without falling foul of the regulatory
regime. This makes it impossible for the right locus of integration to be
developed that can truly consider the cost-benefits of ‘make or buy’ decisions.
Since both the development of CCGs and the commitments to competition and
patient choice in these particular ways remain cornerstones of the coalition
plans, it is doubtful that they will produce anything like clinical integration that
has been successful in the US.