The bravest leaders are ensuring outcomes are prized above activity – but this is not a mission for the faint hearted, say Diane Bell and Nicholas Hicks
What have the health economies of Bedfordshire, Bexley, Cambridgeshire and Peterborough, Camden, Croydon, Milton Keynes, Richmond, Salford, Sheffield, Somerset and Staffordshire all got in common?
They all have leaders who are changing the incentives in their health economies to reward achievement of the outcomes that matter most to local people.
These leaders know that such innovation is not risk free. They also know that to do nothing and continue navigating the NHS into the activity-incentivised rocks carries far more risk for both taxpayer and patient. The mounting payment by results contracting catastrophe has already given us both declining service quality (increased waiting times) and a £2bn provider overspend.
Providers’ new alliances break down the traditional barriers between primary and secondary care, health and social care, prevention and treatment, and mental and physical health. Providers will also have taken on population health responsibilities, introducing systematic ways to understand and reduce individuals’ risks of future ill-health and avoidable use of healthcare.
Longer term contracts will make it easier to focus more on prevention and invest in services whose clinical and financial return may take several years to achieve.
’However understandable the reasons for these skills gaps, they must never excuse staying with the failing status quo. We need to learn from the innovators with the courage to do things differently’
Success requires the exercise of skills, capabilities and behaviours currently sparse in the NHS. Few NHS organisations can manage population health, support shared decision-making, or coordinate care across traditional boundaries. Economic expertise to accurately model the impact of services on outcomes is rare in the NHS.
Depressingly few organisations even understand their own unit costs, or are equipped to design, plan and implement major system (rather than institutional) change, or manage complex logistics well. These are all now mission-critical tasks.
However understandable the reasons for these skills gaps, they must never excuse staying with the failing status quo. We need to learn from the innovators with the courage to do things differently – and we already have positive lessons:
- When asked, the public describes outcomes in more functional and social terms than we are used to. Older people want help to stay independent and if they get sick, to recover their independence (eg Oxfordshire). And that’s a great way to reframe and ‘de-medicalise’ problems.
- Clinicians want to work with each other and with patients to design new systems of care that they are committed to delivering (eg Salford).
- Contracts asking for and rewarding delivery of outcomes catalyse provider arrangements that make integrated care easier to deliver (eg Croydon, Somerset, and Cambridgeshire & Peterborough – despite this contract being terminated).
- Rewarding outcomes leads to using outcome data to manage services. Patients make more informed choices about the type of care they want, not just about where it will happen. When patients are routinely given “real world relevant” PROMs data, they choose invasive treatment about 20% less often (eg Bedfordshire).
And we can also learn from when things haven’t gone to plan:
- Provider alliances have not always fully involved general practice in the development of their plans – and they need to be included if good population health management is to be achieved. A system-wide outcomes-based approach could be one indication for the formation of GP federations.
- Moving to an outcomes-based approach makes change easier to understand, although it doesn’t make it easy to do. Many of the initial relationship problems with Bedfordshire’s MSK contract could have been reduced had there been more open dialogue pre-procurement between the commissioners and clinicians and managers in the main providers.
- Sometimes, the nature of the contract (multi-year, capitated, outcome incentivised) and the procurement method (competitive or non-competitive) have been conflated. These issues should be considered and decided separately. From Sussex to Sheffield, similar specifications for integrated MSK services have been procured using different methods. The differing times taken to get to contract award and paces of implementation have reflected the commissioners’ contracting. But the similarities in delivery of more person-centred care and more efficient healthcare utilisation reflect the impact of taking a population and outcomes-based approach.
Although many commentators – HSJ included – may not have recognised it, and in the wake of NHS England’s New Care Models programme and latest planning guidance, there is a growing movement towards population and outcomes-based “accountable” care.
We can learn from and build on the successes and failures of those who have been brave enough to go first. As the Health Foundation says: “It is hard to dispute the logic that it is right to focus on the outcomes that matter to a given population, combined with the alignment of incentives and indicators to drive improvement and co-ordination between providers.”
Dr Diane Bell is director of Insight for Cobic. Nicholas Hicks is a founder and chief executive