Lessons from Boston on integrated care


by Pam Garside


In November 2012, Emma Stanton and I took a group of senior people from the public and private sectors of UK health to Boston to explore “value-based healthcare”. Emma is a practising psychiatrist who spent her Harkness Fellowship year in Boston. We arrived just after President Obama’s re-election victory, which was incredibly exciting unless you’d happened to support Romney.

‘Financial success does not equate to value, piecemeal financial gain does not contribute to system value’

The best election-related story was the traffic jam of private jets on “election eve” at Boston’s Logan airport for the Romney party which never happened… such misplaced confidence.

Our group visited the leading academic and healthcare delivery institutions in Boston, a city described by the British Consul, who hosted a reception for us, as the “capital of clever”.

A brief tour of who we met: Michael Porter, arguably the most famous strategy professor globally from Harvard Business School; Tom Lee and Kelly Hall from Partners HealthCare, the biggest acute delivery system in the city; Brian Wheelan from Beacon Health Strategies, a managed mental health company; James Heywood, a co-founder of PatientsLikeMe; Arnie Epstein from the Harvard School of Public Health; Maureen Bisognano from the Institute of Healthcare Improvement; and a lot of clever young entrepreneurs at MIT Media Lab

In my view, three themes that emerged from the trip were: the pursuit of value, the relentless use of data and talent linked to innovation.

Pursuit of value

Value was defined as outcomes achieved per pound or dollar spent. We must dramatically improve value; that is the only win-win goal, and one that is acutely relevant to integrated care.

What is needed is critical mass of organisations practising integrated care and measuring outcomes and an ongoing dialogue, not just soundbites. Integrated care is perceived as “a very slippery phrase” in the US. Amen to that in the UK.

We heard that financial success does not equate to value, piecemeal financial gain does not contribute to system value and the system can also have competition between integrated organisations to serve patients well.

‘On both sides of the Atlantic we have been measuring the wrong thing at the wrong level’

Process measurement and improvement are important tactics but they are not substitutes for measuring outcomes and costs. We must align pay with value and we have to get paid differently: fee for service and global budgets lead to “bad things”.

Payment has to reward the right things and align to the right unit of value: the care of the patients, clinical outcomes and even innovation, as demonstrated by examples from the Geisinger Health System. Geisinger is an integrated delivery and payment system, not unlike Kaiser Permanente, in Pennsylvania and known for innovation.

An interesting observation is that traditional disease management has not worked because the basic substructure on which it is imposed is so “screwed up”. Traditionally, disease management in the US tries to manage patients’ conditions across a variety of care settings, but there is no galvanising or uniting goal (ie: a goal to which all parts of the system are working). A management system imposed from above with no incentives for real clinical change doesn’t tend to work.

Measurement and use of data

The people we visited are making a science of performance. On both sides of the Atlantic we have been measuring the wrong thing at the wrong level and we need to deal with whole cycle of care to deal with the problem.

We tend to think of measurement a something we go back to and look at, but it has to be continuous, making information continuously available. All great high value organisations measure all the time.

We need to inject sophisticated measurement into our health systems and use them continuously. The UK should be further ahead than it is in the whole field of clinical reporting and outcomes measurement despite all the good efforts of NHS medical director Sir Bruce Keogh.

‘We were struck by how little we understand the business we are in, that US colleagues can slice and dice their business analytically’

Our US colleagues exhorted us to start with the people willing to participate, give people an exciting time doing it, have a working database and stress that individual magnificence is not enough. We also observed that you need a very evolved leadership.

A point of contention with which most of us disagreed was that we can rely on clinicians just wanting to do better, so there is no need to publish outcomes to patients or the public. We saw examples of measuring and managing mental healthcare delivery and outcomes using good data and patients with a number of diseases being involved in tracking their own state of health and producing a unique database.

Beacon Health Strategies uses data on outcomes in managing mental healthcare across boundaries as a prime contractor and PatientsLikeMe is a data-driven social networking site that enables its members to share condition, treatment and symptom information to monitor their health and learn from real outcomes − it is bottom-up data collection by the user.

Big data is here

Another striking thing is the burgeoning opportunity to absorb data from multiple sources to the benefit of individuals and populations.

“Big data” is a collection of data sets so large that traditional database management tools cannot process them. It is increasingly being used across sectors, including healthcare, due to increased capture of electronic activity.

We have to take advantage of it for the UK population. Indeed, we commented that we have the materials in the UK − a series of national systems and data registries − and we would be crazy not to exploit this for the benefit of people here.

We were also struck by how little we understand the business we are in, that US colleagues can slice and dice their business analytically using multiple metrics and have a deep
understanding of where they are and how they are doing. Patient and information director Tim Kelsey’s programme for the NHS Commissioning Board will be a crucial platform for these types of developments.

The election campaigns, especially Obama’s, understood the importance of data. The campaign appointed a chief scientist and set out to “measure everything”. Nate Silver is the statistician who correctly predicted the outcome of the 2012 election in every single state in The New York Times. He says: “Numbers aren’t perfect, but for me it is numbers with all their imperfections versus bullshit.”

Talent and innovation

It was striking that Boston has so many world class universities concentrated in the city, the most obvious being Harvard and the Massachusetts Institute of Technologyin Cambridge.

‘We can do these things in the UK in our own way. We have a running start with our “system-ness” and willing people’

Health is a significant part of their focus − given the size of the market they would be ill advised not to focus on health. In Cambridge, multinationals including Amgen, Biogen, Genzyme, Novartis, Pfizer, Google and Microsoft have large offices clustered next to the campuses.

The MIT Media Lab has an eclectic cross-profession mix of young people at a variety of educational stages, many of which had already formed start-ups and have entrepreneurial ambitions.

Venture capital is an issue here as in the UK, but failure is regarded differently, almost as a badge of honour, in the US. There is no stigma attached to it. The graduate students seem unworried by debt as they know they will repay it. Equally, Harvard has such an astonishing scholarship programme due to its eye-watering endowment that many lucky young people benefit.

Celebrate failure

There is a striking atmosphere of cross fertilisation and of involving and encouraging talent. We were regularly joined by students in our sessions and IHI showcased its (admittedly
older) UK quality improvement fellows funded by the Health Foundation.

The usual questions and lessons about innovation struck us: why do large organisations not innovate from within? Incumbents are unlikely to innovate and therefore be open to “outsiders”. You need to allow time for things to succeed or fail, and then celebrate failure.

Healthbox, currently running a successful health accelerator in the UK for start-ups, had just finished its Boston programme and there was much discussion of venture financing for start-ups and post-start-up companies, the lack of it in the current economy and the need for enlightened investors.

It was great trip, thanks to hugely generous hosts. We can do these things in the UK in our own way. We have a running start with our “system-ness” and our willing people.


This was originally published on HSJ.co.uk on the 9th January 2013.