HSJ EXCLUSIVE NHS capacity chief warns of potential for lowering treatment thresholds

Published: 10/03/2005, Volume II5, No. 5946 Page 13

Patients are being offered surgery they may not need - and perverse incentives under payment by results could be to blame, NHS head of capacity, plurality and choice has warned.

The payment by results system still has 'pretty basic flaws' and commissioners and the Department of Health need to 'raise their game' if they are to avoid gaming in the system, Bob Ricketts warned.

Speaking at a HSJ conference on patient choice last week, Mr Ricketts said the right way to address the impact of payment by results on demand was the 'million dollar question'.

'That is not being pejorative about clinicians or managers; It is just saying that under a payment by results system, unless you have actually got tight pathways and thresholds agreed in advance, there is an ability, as more capacity comes on stream, to lower treatment thresholds, ' said Mr Ricketts.

'You could argue that patients benefit from that, as more get treated.

Although you could see a situation where patients are actually offered cataract surgery and there is a fairly arguable case in terms of visual acuity - so there is quite a big potential for gaming in the new system.' Mr Ricketts said confident commissioning would reduce this potential, adding: 'I think this requires a raising of the game by the department [of health] and commissioners in terms of how we think about managing demand.' He admitted a lot more work had to be done to make payment by results work but told delegates it was an 'essential lubricant for system reform'.

'If we do not get payment by results right we will foul up on system reform.

'It is fundamental to choice, it is fundamental to plurality, it is fundamental to the major shifts we need to deliver.

'So we need to make it work. We also need to make it work in the right way so it doesn't create perverse incentives, ' said Mr Ricketts.

'There are still some pretty basic flaws in terms of payment by results, but it is on track. The evidence that I have seen so far is that it will work and patently there will be winners and losers.

'That is a message for commissioners who could turn out to be the biggest losers in payment by results if they do not tackle the issues around demand.'