The Empty Taxi
It is vital that the integration taxi delivers. Over the 20th century, the clinical community has demonstrated an amazing ability to learn, adapt, apply technology and consolidate. This challenge needs the same intent but a new set of tools.
Churchill denied that he quipped about an empty taxi pulling up at Number 10 to let the Prime Minister out. The illusion would have slighted the occupant but these days we tend to expect more of our empty taxis, especially in murder mysteries or when a superhero is on the loose.
It would be cruel and simplistic to say that the NHS tends to pull off the opposite illusion: that taxis full of ideas fail to disgorge much at all when their doors flop open. Nevertheless, it is worth asking whether the line of STP taxis is another exercise in planning on paper or if something spectacular will emerge.
A big STP idea is integration: acute services with single-points-of-entry and one-stop-shops, or joined-up services and connected care in the community. In one way this is an empty taxi because the NHS’s experience of integration is mixed. Managerial and financial aggregation, for instance, have produced larger organisations without really addressing core operational challenges or taking the silos – especially the conceptual constraints – apart. More worryingly, the dynamic favours size over effectiveness when takeovers take place. Meanwhile integration through information technology has produced high profile failures for three decades or more.
So why is integration so difficult in healthcare?
My guess is, first, that the 20th Century’s massive medical advances came not from integration but from specialisation. Success (and the recognition of success) lay in creating units, sometimes hospitals, dedicated to specific diagnoses or treatments. To reverse a century’s worth of success as we face the long-term and the comorbid is asking a lot. Second, it is hard to articulate what health is about in operational or business terms, but that is what integration requires. Industry has always had clear goals in terms of survival and profit, and that drove investment. Wal-Mart, for instance, installed satellite communications in the early ‘80s and spent $4B on a supplier network in 1991 (not much less than Connecting for Health, but a decade earlier). The logic was simple: you can’t sell a TV or a garment while it lies in a warehouse or travels in a truck, so shortening the trip to the store makes money. Ironically, as the medical miracle was climaxing in the late 20th Century the commercial world was already moving into integration.