In UK Primary Care, it has been promoted first in Community Care and now via the assortment of people being hauled aboard the PCGs. In the United States, integration has proceeded in a variety of ways, most of which have been much more commercially driven. The HMO must be able to offer a good portfolio of services, and run them efficiently. Rather like Direct Line Insurance moving into car repairs, or banks diversifying into almost every aspect of personal finance, the business aims are to take control of costs and create a captive customer base. Integration, in the sense of keeping track of every patient's interaction with the providing institutions, becomes essential for the management of the total enterprise.
Integration undoubtedly offers both direct and indirect benefits to patients.
Direct, for example, in that they can expect that their records will follow them around easily at all points in the system, and indirect in that costs ought to be lower and the service provision more coherent. The sensitivities involved in this kind of activity were illustrated by a debate that developed in Canada during 1996. This was not actually about the use of patient-identifiable data, but the selling of records that would reveal the prescribing patterns of individual doctors. The objections of the medical profession were directed not so much at the principle of monitoring of these patterns, as the carrying out of it by a commercial organisation, IMS 7 . In contrast, a more amicable arrangement was arrived at in respect of VAMP's database, with Reuters' decision to sign it over to the Department of Health 8 .