In response to Circle’s piece on lessons learned from its first year in Bedford, Kerry White and Paul Tisi reflect on Bedford Hospital Trust’s experiences of commission outcome based incentives

The aim of innovation and reform in the NHS should be to make the service to patients better and the system more efficient. If that doesn’t happen, all the high flown rhetoric about choice and competition means nothing. So what have we learned and what does the wider NHS need to learn from our experiences of commission outcome based incentives (COBIC)?

‘There are still delays, contrary to claims 100 per cent of patients are triaged within 24 hours’

A new system and new pathways are likely to have teething problems. Yet the musculoskeletal contract in Bedfordshire is now 18-months-old and still there are delays in patient referrals of up to 46 weeks, contrary to the claim that 100 per cent of patients are triaged within 24 hours of referral

Secondary care referrals may have been reduced at Bedford Hospital, but the nearby private hospital is thriving with simple MSK surgery. 

Patient impact

Kerry White

Kerry White

The impact on some patients has been suboptimal. Some are placed on treatment programmes that are of no benefit to them at all, delaying but not preventing referral to a specialist. Twenty per cent of GP decisions may have been changed, but what evidence is there that the new decision, rather than the original one, is the correct one?

Take the experience of one patient who was referred with knee pain to the triage hub on 3 September last year. They were diagnosed with osteoarthritis at a physiotherapy appointment at an unstated date, eventually was investigated with MRI on 20 May where a meniscal tear was diagnosed and referred for consultant opinion on 26 June.

‘This does not appear to be patients exercising their choice’

Another patient reported being seen by her GP on 26 January for a problem with her left knee and referred to the Circle MSK service. She was advised two weeks later after “paper triage” that a course of physiotherapy was required, which started on 18 March. At the appointment with her GP and on hearing from the MSK service, she expressed her wish to be referred for a consultant opinion. Only after the physiotherapy appointment was she referred to a specialist and subsequently underwent surgery.

This does not appear to be patients exercising their choice nor does it offer anything towards reducing wait times. 

Referral delays

A local GP wrote to the trust: “I work up a patient, be it for a knee or hip, refer them directly, perhaps to yourself, obviously requiring a hip replacement, having had the appropriate imaging and physio and these get intercepted, the patient delayed, suggesting that they now need a scope assessment prior to being referred on. This often involves a delay followed by a physio delay and then they write back to us saying we are now referring onto the orthopaedic department.” 

Paul Tisi

Paul Tisi

These are not isolated incidents. Between mid July 2014 and mid July 2015 more than 200 patients referred to Bedford Hospital had delays from the triage hub receiving the referral from the GP to the referral being sent to the hospital of between seven and 46 weeks. A further 26 patients had no details of their clock starts because the inter-provider data transfer form had not been sent with the referral. More delay has been introduced by batching referrals. 

On Christmas Eve last year Bedford received no less than 250 referral forms and a New Year gift of a further 100 on 31 December. Who is capturing this data to ensure the system is working well for patients?

‘Who is capturing this data to ensure the system is working well for patients?’

If the patients are not necessarily benefiting, it has been claimed that the taxpayers are. It is well recognised that loss of income on the elective side - a large proportion of the less complex patients being switched to the private sector - leaves the trauma service unsustainable. A further knock-on impact of the contract on Bedford Hospital is the significant impact on junior doctor training which then exacerbates the potential problem with trauma services. 

Radical changes

So what can we learn from this? First, that radical changes to patient care systems need to be carefully tested before being brought into operation, otherwise patients lose out.

Second, that efficient data sharing and registration need integrated information systems, which are certainly not currently present in Bedfordshire.

Third, the effect on the whole health system needs to be thought through pre-tender. If a prime contractor model erodes the viability of essential services such as trauma because they become clinically and financially insupportable, have we got it right for the NHS?

‘The ambition to contain cost and improve quality is certainly not proven so far in Bedfordshire’

We also know that the commissioners, at least in year one, ended up more than 10 per cent overspent on the “flat fee contract”, so the COBIC ambition to contain cost and improve quality is certainly not proven so far in Bedfordshire. Indeed, all the local enthusiasts for this novel “pilot” have moved on from the clinical commissioning group.

With the NHS seemingly facing a growing financial challenge, innovation is a must, and the NHS needs to learn quickly from “pilots” and roll out those lessons. For the local stakeholders, patients, the hospital, the CCG, GPs and Circle, there are various views about what is good and the learning from this work. 

The trust’s current view is that system change has attendant risks. Unless these are rigorously worked through early on, the contract is water tight, and time is taken over implementation, the patient and the service may well end up worse off than the high ideals that were intended.

The trust has long been asking for an independent review to look at the clinical and financial impact on the system so that we can put right things locally and so that the wider NHS can learn from a “warts and all” review.   

Kerry White is divisional director for planned care, and Paul Tisi is divisional medical director for planned care, both at Bedford Hospital Trust—-