Professor Schrijvers's editorial raises some important challenges for everyone interested in integrated care. It also strikes a particular chord here in the UK (or at least in England), where a series of recent reforms have begun to introduce greater elements of choice and competition into a system that has often been seen as something of a public sector monopoly. However, many UK commentators have struggled to think through how best to combine competition and collaboration—especially when you may need to do both at the same time! For example, some people would feel that greater competition is an important incentive when it comes to elective care, encouraging hospitals to keep their waiting times to a minimum and improve the quality of their care. However, the same hospitals that are competing for elective patients might also need to collaborate with each other to ensure that there is an appropriate mix of local minor injury units and regional specialist services to meet the needs of emergency patients. Similarly, current policy is encouraging health and social care providers to integrate their services, yet this runs the risk of creating a local monopoly and thus undermining choice and competition.
For me, the current emphasis on competition may be the wrong place to start. While competition can be channelled to produce different services and different outcomes for patients, the key thing for me is what mechanisms we use to change behaviour in front-line health and social care agencies. In England, we have often tried to change behaviour by the power of ideas (exhorting people to change) or by regular structural reorganisations. Over time, this seems to have had very little impact—sadly, the power of ideas by itself does not seem enough to convince people to change what they do, while reorganisation in England has become so common that it has actually made many services highly change resistant. Instead, I believe that you start to really change behaviour only when you start to change accountabilities and incentives. One of the reasons why competition seems to have such a potential impact is that it asks providers to whom they feel accountable—to their Royal College or professional association? To their peers? To their chief executive? Or to their patients? Without some form of competition and economic incentive, many systems have struggled to persuade health services to feel accountable to the latter group, who are all too often supposed to feel grateful for the system offers them.
However, current approaches to competition are only one way of changing accountabilities and incentives. In one English hospital, the chief executive proposed basing part of doctors' pay on patient satisfaction ratings. In my field (social care), people who use services can receive the cash equivalent of directly provided services to commission their own care and hire their own staff (a system known as direct payments). Both these are examples of trying to change behaviour by changing incentives and accountabilities—and ultimately this may be a more helpful way of approaching the issues at stake than by simply contrasting competition with a lack of competition as potential strategies for reforming services.