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Nick Goodwin: Gesundes Kinzigtal is ahead of us – vanguard areas in England compared with Kinzigtal

Nick GoodwinDr. Nick GoodwinDr. Nick Goodwin, formerly a Senior Fellow at The King’s Fund and now Chief Executive of the International Foundation for Integrated Care (IFIC) just spent a few days with a delegation in Baden-Württemberg viewing the integrated health care offered by Gesundes Kinzigtal. In this interview he speaks about his impressions and draws a comparison between Gesundes Kinzigtal and the vanguard areas, which chief Executive Simon Stevens recently declared to be possibly models for future health care in England.

Mr. Goodwin, you have just been in Germany to have a look at the integrated care system Gesundes Kinzigtal. What could we learn from the English projects – the vanguard areas –, and could they learn from us?

I was really impressed by the business structure of Gesundes Kinzigtal. I had already heard and read a great deal about it before, but only now do I understand the business model and the resulting positive stimulus for the improvement of quality of healthcare and the maintenance of health. What was particularly interesting is that the model was developed completely independently of the respective healthcare system (whether medical insurance or state system); all that was required was a reliable source for the respective national healthcare costs per person and morbidity, and the assessment of the actual expenditure per person in any region. Cooperation with local services and other support facilities, financed by third parties such as professional associations, pension funds etc, is unfortunately, very much like in England, a challenge. However, in this too Kinzigtal is ahead of us in that regional management already exists, whereas in our case the PACs (one form of the vanguard areas, the integrated primary and acute care systems, which will be tested) still need to be set up.

As the Chief Executive of the International Foundation for Integrated Care you have a good understanding of international developments in future-oriented regional healthcare. How do you see the vanguard areas or projects such as Gesundes Kinzigtal in this context?

Unlike the vanguard models in England, which focus on new forms of integrated provider groups that may compete with each other for patients, Gesundes Kinzigtal has taken a population-health perspective. On balance, I prefer this Gesundes Kinzigtal approach since it focuses directly on improving health to a defined community.

I think we cannot avoid better organizing health services at a “meso-level”, with a regional size which is still manageable. Accordingly all regional projects which build infrastructure for this are important. A national administration cannot generate the “spirit” that can develop from local cooperation. But, we know from the NHS experience, to create only additional infrastructure is not enough as it often results in new bureaucracies.

This is why the Gesundes Kinzigtal approach has inspired me. After a once-off investment, regional infrastructure is financed solely from savings in costs in relative terms; this prevents the creation of unnecessary, unproductive bureaucracy. And the better the health of the regional population, the more the progression of disease can be prevented, and more care is taken in dealing with drugs, nutrition and physical changes, the better the result. Simply wonderful. Given demographic developments and the challenges of constant increases in cost and performance in the classical fee-for-service systems, I am firmly convinced that such developments are the future.

The vanguard areas:

The English NHS is considering fundamental reforms in the healthcare system. Chief Executive Simon Stevens recently declared 29 vanguard areas that could be a model for future health care in England. Over the next five years structures, processes and cooperation between sectors and within the communities in these vanguard areas should, as part of a Five Year Forward View, and with the support of the NHS, be further improved. Patients should be more closely involved, and access to specialist services such as dialysis should become easier. This integration process could go so far that it becomes organized by management groups or even lead to new, legally integrated “community providers”. A 200 million pound Transformation Fund to support the change has been created. The objective, amongst others, is to ascertain, on the basis of evaluation, which projects and organizational forms are suitable as a model for the entire NHS healthcare system. More about the vanguard areas under https://www.england.nhs.uk/2015/03/10/new-era-of-patient-care/.

 

Which projects of the vanguard areas do you believe hold the most promise, and why?

The vanguard areas will have more freedom in organizing themselves, including the integration of budgets for different sectors; however – they will not, besides cost-free consultation, receive any additional financial support for this change management. The danger does exist that, as is so often the case in the creation of new structures, it will fail due to insufficient investment. Three forms will be tested:

  • The first form, “multispecialty community providers (MCPs)” could be equated to the term “Medical Home” in the USA. The idea is that local primary health centers should be extended to include other professions and specialist care, including from social care, and operating as a new type of group practice organisation.
  • The second form, “integrated primary and acute care systems (PACS)” should lead to either complete and legally integrated, cross-sectoral organizations or to ACO-like management organizations which, in turn, contractually bring together general practitioners, hospitals, counseling centers, paramedics in collaboration for the benefit of the patients. Again, the focus is on creating a new type of provider organisation, in this case to manage care more effectively across care pathways.
  • The third form, “models of enhanced health in care homes” is intended for that special group, the elderly, who should enjoy better care and rehabilitation in nursing homes.

I believe that the models defined in the first and third groups have a good chance of successful implementation; change, however, is more likely to be incremental. I find the solution offered in the second group very interesting but challenging.