Despite its reforms, the currencies that drive activity and behaviour in the NHS remain rooted in the past and need urgent attention

The NHS has now entered its post-reform phase. Clinical commissioning groups are set up and health and wellbeing boards are also starting to become operational. Change will take time to become apparent but the early shoots of change and localism are there and will no doubt become more apparent.

‘The currencies for acute care actively impeded the aspiration of integrated care’

The likelihood is that the health environment will get noisier, with local prioritisation of services proceeding in the bright glare of a transparent environment. If we add the inevitable rash of reconfigurations around the acute sector to this, we can be sure health will fill many column inches over the next few years.

The currencies that drive activity and behaviour in the NHS, however, still remain rooted in the past. They are becoming more and more anachronistic and they need urgent attention if the dreams of integration, population health, whole-person value and citizen empowerment are going to become reality in my (or your) lifetime.

The currencies for acute care actively impeded the aspiration of integrated care. They basically reflect activity and do not fit within a capitated health system where managing care within a defined fiscal envelope is essential.

It is difficult to see how foundation trusts can ever be really part of an integrated care approach when their very oxygen is driven by a currency which is the antithesis of a capitated system. Yes, it is possible to suspend national tariff and institute local arrangements but only if both parties agree to do this. The FTs retain the “get out of jail” card whereby they can revert to national tariff, should local arrangements in any way threaten their financial viability. We urgently need a balanced mechanism to manage this impasse.

New currencies

New acute currencies could be phased in if there is the will. They could incorporate a range of measures including year of care outcome-based metrics for chronic diseases, population health metrics reflecting local need and influenced by CCGs, and personally determined metrics reflecting patient goals.

‘Paradoxically, all too often, a good financial crisis is the inevitable precursor and driver to real change’

Emergency care could be marshalled using “collar and cap” approaches, which would have the potential to align the interests, leaving the potential escape valve of mechanisms to manage the sudden or sustained increase in activity if they fall over a predetermined threshold.

To move in this direction, one thing is essential − heading from the sterile biomedical disease-focused care models to whole-person ones. The fixation we have with disease entities is outdated and unable to really embrace non-health determinants of health which as we know deliver the majority of value for patients and populations.

Shifting the dinosaurs

Currencies in primary care also need urgent attention. The quality and outcomes framework needs to accelerate the shift in emphasis to embrace population health outcomes, not retain an obsession with individual medical targets. This will ensure CCGs are focused on the needs of their populations, not on the attainment of medical targets, which can ignore the real requirements of populations.

Again we need to move away from diseases to whole people, as if we do, new metrics around patient reported outcomes become possible at scale as it is assumed people can suffer from more than one long-term condition.

A direction needs to be signalled and a pace of change determined. We do not have the luxury of waiting until the financial situation is more favourable. Paradoxically, all too often, a good financial crisis is the inevitable precursor and driver to real change. 

Healthcare delivery has been described as a series of vertical drain pipes with a dinosaur sitting on the top of each of them ensuring the contents never escape and are allowed to mix. The dinosaurs need unseating and a change in the currencies is equivalent to a mortar charge. It is not only the euro that requires wholesale reform, our health currencies also need change urgently.

Charles Alessi is chairman of the National Association of Primary Care

Commissioning show 2013 logo

Charles Alessi will be speaking at the Commissioning show at the Excel in London on 12-13 June. For more information and a full list of speakers visit the event