Blog Post

You can't create integrated care systems without primary care. Period.

October 10, 2019

    We've talked before about how global health systems are rushing to un-fragment our siloed health systems. I spend a lot of my time sharing insights and lessons learned from one part of the world to the next.

    13 tools to help partner with GPs and transform the primary care delivery model

    But unfortunately, while many of us are borrowing successes, we're also mimicking failures. The one I see most? The notion that "we can build integrated care systems without primary care at the table."

    Partnering with primary care may seem 'too complex'

    There's a small but vocal minority who don't think primary care is needed to help drive health system transformation. Instead they argue, "Just pay primary care differently and their model will change." They're businesses after all. 

    However, the majority bypass primary care for a more legitimate reason: it's a transformation unto itself. Globally, the primary care delivery model is often not set up to manage in the integrated care world we're envisioning. Most GP groups operate 9-to-5, which makes being the first point of contact for care extremely difficult. Further, many GPs work alone, and even if they wanted to, expanding the care team for skills or access is cost-prohibitive for many.

    The result is a problem seemingly too complex to bite off right now. So many throw up their hands and forge ahead without empowering primary care as a key leader and architect in this new model. But you sideline primary care at your peril. The English integrated care systems (ICSs) have come to this conclusion the long way. Despite plans on managing populations since 2016, it took a National Health Service (NHS) mandate for GPs to take part in an ICS in 2019. Up to that point, many GP groups just stayed on the periphery.

    One of the newest versions of integrated systems comes from Canada with the Ontario Health Teams (OHTs). While still in early development, OHTs face the same structural and funding challenges seen elsewhere. It's a reality the Ministry has acknowledged: Primary care isn't a required partner to be an OHT, only a suggested one. However, it is likely that an OHT without primary care as a partner will have a harder road from the start.

    How to successfully include primary care from the start

    My guidance for an ICS or an OHT or an accountable care organization (ACO, the U.S. version) is this: Place outsized time and energy on building relationships with primary care groups. Consider these three principles:

    1. Sell a vision. Tell the story of what this new system will look like and why you think this organisational model will solve some of your local market's biggest challenges. Don't forget to make it compelling to them.

    2. Collaborate, don't dictate. Bring primary care in as a partner and work together to sketch out what your integrated delivery model will look like and how you will transition to this new way of working. It's sometimes easy to illustrate the end goal, but much more difficult to define the start line.

    3. Hospitals: recognise your size and scale. Independent groups lack the resources needed to re-invent their care model. Leverage your staff, expertise, and sphere of influence to help transition the primary care model into something that meets the needs of the system, GP, and patient.

    For much more detail on how to navigate those three steps check out our research study, The Primary Partnership: Working with GPs to Transform Care.

    And please join me and my team for a workshop in Whitby, Ontario on 12 November, where we'll discuss no-regret strategies for building integrated care systems. Email James Cowling at to reserve your spot.

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