Published: 08/07/2004, Volume II4, No. 5913 Page 27
Hospitals are not the bad guys, says Noel Plumridge
Patrick Kavanagh, in one of his poems, recalls approaching an agricultural job 'with the enthusiasm of a man who sees life simply'. The image sprang to mind during May and June's flurry of conferences, press releases and Department of Health roadshows proclaiming improved chronic-disease management as arguably the biggest NHS policy direction.
The new-found enthusiasm for better care of the chronically ill is readily apparent, and the vision still seems disarmingly simple.
Take, for instance, the assertion that between 1900 and 1950 the prime business of the health system was treating infectious disease. From 1950 to 2000, infectious disease having been fixed by antibiotics, the focus was on improving the effectiveness - and latterly the efficiency - of acute hospital care.
Now with successful treatments extending life expectancy for cancer sufferers, AIDS victims and many other groups of patients, the emphasis in the first half of the 21st century must move to the care of the chronically ill.
It is a persuasive historical perspective.And, like many sweeping generalisations, it contains an essential truth, but skirts over many complexities.
One of the biggest, which is still exercising the DoH, is how improving chronic-disease management can be squared with the new payment by results funding system.
For English health policy is still largely preoccupied with the efficiency of acute hospitals. At national level the targets may be changing, but week in, week out NHS managers in England are still implementing the enormous policy initiatives - payment by results, patient choice, the creation of foundation hospitals - that will together create a market system aimed at enhancing hospital efficiency.
This may be the business of 1950 to 2000 but it is far from complete, and many a hair will turn grey between now and next April as accountants try to make payment by results work in practice.
And here lies a conundrum:
paying hospitals by the 'spell' offers hospitals a direct financial incentive to admit more patients.
One more spell, one more tariff payment. But good practice in managing chronic illness, particularly in its early stages, is to build self-management and mutual support among patients, and to do everything possible to avoid using hospital beds. This inconsistency has been provoking questions at the DoH roadshows.
A deeper theme is a growing sense of impotence among commissioners. Primary care trusts, expected to reduce emergency inpatient bed days by 10 per cent by 2008, must be wondering where their effective leverage lies in the emerging world of foundation hospitals and patient choice.
There are signs that the DoH, albeit belatedly, is recognising the development needs of commissioners. Their exposure within the market system, and the consequent financial risk to the NHS during a period of rapid change, has been apparent for some time. The recent Hudson report on the management of PCTs highlights the fact that twothirds of PCTs do not have a dedicated finance director.
Now, with budget responsibilities growing and management capability already thin, PCTs are being asked to mutate into sophisticated commissioners and demand managers within a system that has been dominated by short-term targets. Assurances of PCT immunity from reconfiguration may reassure staff, but investment in skills and leadership is also vital.
To meet their chronic-disease care targets, the key challenge for commissioners is this: what incentives for acute hospitals are powerful enough to persuade doctors not to admit the chronically ill unless there is a compelling need?
For years we have been urging acute hospital clinicians to become ever more productive.
Now we are putting in place a funding system that rewards them for the extra activity, and at full cost. It would be surprising indeed if they do not respond.
And although the new general medical services contract gives PCTs scope to encourage the essential building blocks of community-based chronic illness care this will not in itself realign the pattern of care.
However, just as the neat historical division between the past 50 years and the next 50 is simplistic, so is the apparent contradiction between systems that promote acute efficiency and the new emphasis on building alternatives to acute care for the long-term sick.
Of course we need both.We need efficiently managed acute care in the 21st century just as much as in the past, and there are signs that the benchmarking that lies at the core of payment by results is already steering trust management attention towards financial outliers - departments or function that appear out of line with what others are achieving.
Sometimes, listening to the proponents of American-style chronic-disease management, one might be tempted to think that acute hospitals are somehow 'the enemy'. But if there is an 'enemy', it is a naive approach to commissioning:
one that supposes that commissioners can, through challenge and negotiation, find 'savings' in acute care that can be 'released' for investment in new community services.
This is still seen as the PCT mission.Yet it is an ambition that has consistently failed in the past.Moreover, it disregards the issue of efficiency in the non-acute setting, where measurement is notoriously underdeveloped.
Last autumn, I argued in this column that budget pooling across each chronic-disease care pathway, using the powers introduced under the 1999 Health Act, is the most likely tool for achieving integration. I stand by this, and suggest that the commissioner perhaps needs to focus more on the size of each budget pool; the handling of co-morbidity (for instance, people with diabetes who are clinically depressed); and who controls the pool.
Could it be that, in many cases, the body best equipped to co-ordinate the care pathway, fix the appropriate balance between acute and primary care, and drive both efficiency and effectiveness is in fact the acute hospital? l Noel Plumridge is a former NHS finance director and a monthly columnist for HSJ.
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