When you log onto the internet, you generally get a relatively smooth ride through the sites you visit, managing to extract the information you need, pay the bills you owe, and flirt with that nice lady in Cincinnati – and all without thinking about the logistics of your journey. When it’s working well, the service is so well sorted that you really can’t tell that you are moving from one company’s website to another, or even in which country any particular company is based.
The service we get from the internet could be said to be functionally integrated, in that the joins between the different aspects of what it does are invisible, and our aspirations in most spheres of our lives is to achieve that seamlessness, so that there is perfect coordination and no hassle in the complex tasks that we do.
An example to contrast with the Worldwide Web might be the UK rail system, where there is often very poor functional integration; the trains are late, but the blame is passed to Network Rail; the points are frozen but it seems to be the fault of the train company; the train buffet is closed, but that’s nothing to do with us Guv, it’s the catering company; and so on, we all recognise the situation…
In both these extremes, we are talking about service integration – ‘‘what’ we get – rather than structural integration- ‘how’ we get it. Structural integration means that one organisation provides all the functions required; so when the UK train system was still under state control, the stations, the rails, the trains and even the buffets were all part of British Rail, and so there was a notional seamlessness in the organisation that ran the service.
The logic was that if only one organisation was involved, then no bucks could be passed, and the accountability of the system would be explicit and clear. In fact, what happened was that the system became increasingly unwieldy and inflexible, whilst the lack of any challenge to its monopoly meant that there were few incentives for it to be responsive to the needs of its customers; it felt as if British Rail was doing its passengers a favour by carrying them at all, rather than the other way round.
I don’t know whether this story rings any bells for you, but to me there are resonances of the way that the NHS tends to treat its patients, and indeed, many of the reforms of the past 20 years have been intended to make the health service more responsive to the needs of its ‘customers’ and less inflexible to the inexorable tide of progress.
The railway system attempted to create this change by breaking the infrastructure in an apparently haphazard way, with different companies bidding for services, whilst the railway system itself was initially also put up for sale, although it is now back in state control, at least in part. The fear is that the same thing is about to happen to the NHS, and that the only way to prevent this is by preserving the monolith of public provision accompanied by public procurement.
In fact, the situations are being handled very differently, and whilst it is still tempting to think in terms of cock up and conspiracy, the underlying logic has probably been thought through a bit more thoroughly – even if not by all our politicians!. The narrative goes as follows: Monolithic systems are by their nature inflexible and, well, monolithic, but simply dismantling them destroys the inherent advantages of their seamlessness and simplicity. What is needed is a way of keeping tight control of their function and loosening the grip on their form, so that new organisations may emerge that are innovative and different. Such ‘tight/loose’ models are seen in management manuals, and underpin the theory of the commissioner/provider relationship, but have rarely been allowed to develop in the public sector for fear of recreating the kind of chaos that occurred when British Rail was dismantled.
We need strong commissioners working with enough providers to ensure that there is real ‘contestability’ and ‘flex’ in the system, without the providers becoming ‘too big to fail’.
In that model of ‘controlled evolution’, we may actually get some features of the Worldwide Web’s functional integration: organisations that work with each other because the benefits of integrated function are clear, without accumulating the rigidity that goes with structural integration.
Moreover, keeping providers nimble and small, as well as ensuring that the power dynamic favours the commissioners, will also encourage those working in the provider organisations to have a real sense of ‘ownership’ and pride in what they do, something which every reform since 1945 has singularly failed to do.
So let’s not make a ‘weasel word’ of the term ‘integration’: the backlash to the current reforms that seeks structural integration would be entirely counterproductive if allowed to occur. We all a want an egalitarian, efficient, responsive NHS, and to do that we need strong principles underpinning our strategic commissioning, clear accountability preferably based on outcomes, not on mechanical processes, and a plethora of provision, not because we want to dismantle the service, but because we want it thrive
Dr Jonathan Shapiro is a former GP and senior lecturer in health services research at the University of Birmingham