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Impact: This would:

• Improve the poor care faced by older people in the health and social care


• Promote much needed integration between health and social care providers.

• Ensure that incentives are aligned within single commissioning budgets to

focus on patients, thus reversing the perverse incentives that currently exist.

4.4 Flexible primary care provision

In this new landscape, stronger primary care provision is both a positive outcome

but also a necessary underpinning service. Several interviewees argued for a far

more flexible approach, drawing on often citied international examples of best

practice (see box below).

International Examples of Best Practice

Kaiser Permanente: The largest non-profit health maintenance

organisation in the United States which serves nearly 9 million people in eight

regions. It is a virtually integrated system in which the health plans, hospitals

and medical groups in each region remain distinct organisations and work

together using exclusive interdependent contracts. The key feature of the model

is an emphasis on the integration of care- combining the roles of insurer and

provider, and providing care both inside and outside hospitals. This enables

patients to move easily between hospitals and the community and allows for

the active management of patients in primary care through care pathways.110

A report found that by providing a multi-disciplinary and integrated approach

to cardiac care for 12,000 patients Kaiser Permanente has seen a 76 per cent

reduction in all-cause mortality, a 73 per cent reduction in cardiac mortality and

$30 million in annualised cost savings.111

ChenMed: ChenMed is an innovative primary care-led group practice

serving those who are older and which has optimised its delivery system for

risk- and value- based payments, as opposed to fee-for-service.112 Operating in

the United States it differentiates itself through providing specialists at every

clinic, door-to-door transportation and limited ratios of patients to doctors

(375:1 compared to the typical 2000:1113)A report found that through this model

the practice when compared to its peers had increased patient satisfaction,

boosted the amount of time doctors and patients spent together, improved

patients' medical adherence and achieved lower rates of hospital use with 40

per cent fewer days in hospital than the national average.114

Gesundes Kinzigtal: Whilst a key feature of the German health service

system is its institutional fragmentation, Gesundes Kinzigtal is a populationbased

integrated care approach. It organises care across all health service

sectors and is run by a regional health management company in cooperation

with the regional physicians' network and two statutory health insurers. The

population-based integrated care approach is designed to lead to a substantial

population health gain realised by patients' enhanced self-management

capabilities combined with intensified health promotion and prevention within

an integrated care framework.115 A recent medical report found that this was a

"promising approach" which would lead to substantive comparative savings in

relation to normal healthcare.116

110 King's Fund, Clinical and service

integration (2010)

111 McKinsey, What health

systems can learn from Kaiser

Permanente: An interview with

Hal Wolf (July 2009)

112 The Economist, "The problemsolvers" (20 September 2014)

113 Moukheiber, Z, "Concierge

medicine for the poorest", Forbes

(23 February 2012)

114 Health Affairs, The care span:

Innovations at Miami practice

show promise for treating highrisk Medicare patients (June


115 International Journal of

Integrated Care, Gesundes

Kinzigtal Integrated Care:

Improving population health by

a shared health gain approach

and a shared savings contract

(23 June 2010)

116 International Journal of

Integrated Care, Gesundes

Kinzigtal Integrated Care:

Improving population health by

a shared health gain approach

and a shared savings contract

(23 June 2010)


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