Alex Heritage, Chief Executive, shares his thoughts on what we can learn from this New York based healthcare system.
On first impressions you may think that the UK and US health systems have little in common. Perhaps you may go one step further and believe the NHS should actively avoid any links with private payer-led health services. However, on closer inspection my recent experience has highlighted many similarities; rising demands on emergency care, high use of hospital care and rising levels of chronic conditions such as obesity and diabetes.
I first came across the Montefiore Health System in New York in 2016 when researching Accountable Care Organisations (ACO) for a Commonwealth Fund Research proposal. Montefiore has had a long and successful impact over the past few decades allowing them to take part in the pioneer ACO programme.
A common challenge facing both our health economies is how to improve both the quality of care and outcomes for patients whilst controlling rising costs. Ageing populations, new drugs and technologies and rising patient expectations have led many policy makers to conclude that traditional ways of providing and paying for care need reform. The Institute for Health Improvement (IHI) succinctly describes how new designs must simultaneously pursue the three dimensions of better experience and outcomes for individuals; better health for populations; and lower per capita costs (IHI, 2012). This Triple Aim approach is clearly evident in the development of Accountable Care Organisations (ACOs) across the United States. Created through the Affordable Care Act (2010) ACOs are seen as a promising vehicle for achieving reform (Chukmaitov et.al. 2014).
Therefore, it was inevitable that NHS colleagues started to research and enquire about the Triple Aim approach. Ben Collins from the Kings Fund has produced an excellent report (Collins, B. 2018) that summarises the Montefiore health system. Last week I had the opportunity to visit Montefiore’s senior leaders in New York and last week welcomed them to London where they delivered an excellent set of masterclasses. There’s always the temptation to look at other health systems and see what we can learn. However, I think it’s our role to make sure that, when we’re doing this, we’re always considering how we can adapt and apply them in the NHS context. Here are some headline areas that I think are worth exploring further.
Probably the most over used word in 2018 (second to accountable) every senior NHS leader needs to ensure Integration is at the top of their priority list. Whilst this can take many forms Montefiore focus on three key areas of integration:
- Emergency Rooms (Department);
- Patient Transitions;
- Highly Complex Patients.
Focussing on joining up and integrating these specific areas of care allows for a significant impact to be demonstrated. When our new Integrated Care Systems are established they should think seriously about pursuing these three areas first rather than trying to risk stratifying all patients and affecting very little change.
Somewhat uniquely in the US Montefiore have focussed on the wider social determinants that have an impact on people; housing, employment, immigration status etc. By starting in the communities and understanding their individual needs, they can give many examples whereby supporting individuals and connecting them with others around them has reduced their usage and reliance on the care system. The UK is still very slow in prioritising the investment to empower this approach. Initiatives like Well North are starting to highlight this approach but this must be industrialised across many more communities to allow for organic community led ownership.
Whilst the NHS is still listening to internet dial up tones, Montefiore’s fibre-optic broadband approach has weaponised the use of data available to them. The uniqueness of their payer-led and part capitated system allows for more data capture and are maximising the use of this at every stage of a patient’s journey. This allows them to identify high resource individuals, spot trends and make evidence-based investments in specific programmes year on year. Whilst I recognise that there are several hurdles for the NHS and Local Authorities to overcome in order to capture and share data, the focus for senior leaders should be to set out a Data Strategy that is fundamental to system reform rather than a bolt-on left to be misunderstood at Board level.
Continuity of Leadership
My final reflection which I believe is key to the success of Montefiore is the continuity of their leadership over time. I heard stories of their personal journeys, learning from their mistakes and their close relationships with their communities. Our most senior leaders in the UK must create the conditions for individuals to flourish by building long-term relationships and giving them space to grow and learn. Too often, we choose to invest in pilots, hope for quick fixes and place the blame on leaders too quickly. Montefiore highlights the impact of continuity and leaders who are willing to invest in the long-term.
Our Challenge in the NHS
There are lots of excellent examples from the NHS that we should continue to share across the UK and overseas. However, the real challenge for us all is to identify areas of best practice from any health system and see if we can adapt and apply it to our current situation.
The experiences and lessons from Montefiore provide us with some encouraging examples that could help us in our next steps of reform.
References and Links:
Chukmaitov, A., Harless, D.W., Bazzoli, G.J., Carretta, H.J. & Siangphoe, U. (2014) Delivery system characteristics and their association with quality and cost of care: Implications for accountable care organisations. Health Care Management Review 1, 1-12
Collins, B. (2018) The Montefiore Health System: A Case Study. The Kings Fund.
Available from https://www.kingsfund.org.uk/publications/montefiore-health-system-case-study
Institute for Healthcare Improvement (2012) The IHI Triple Aim. Available from http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx