By Dr Diane Bell, Director of Insight, Cobic
NHS England’s Five Year Forward View (5YFV) proposes a vision for delivering high value sustainable healthcare. There’s little debate over what’s needed: more focus on prevention and early intervention; greater control and engagement by people over their own health and healthcare needs; and less fragmented services to support people live the lives they want to lead. 5YFV describes local models that could deliver this vision, based on strengthened primary care or redesigned hospital systems, supported by networks of specialist care. So far, so good.
The question of ‘how’ is largely left to local economies to figure out. Quite right too: in complex environments such as healthcare, the centre is too distant to respond sufficiently accurately or nimbly to local issues. Although enablers of effective and efficient clinical care, such as tariff setting and technology development can be facilitated nationally, those changes will only be effective when translated into each patient having a better interaction with his local healthcare service.
Outcomes-based commissioning is a route through which 5YFV’s vision can become a local reality. Working with communities to describe a set of outcomes that matter to them provides a bespoke mandate shared across the local silos of health (and care) services, underpinned by bringing previously fragmented funding and contracts together into a single capitated budget. Coupling this with a long contract duration further incentivises prevention, early intervention, and innovation. Thus, the ‘administrative’ barriers that have previously stymied efforts of local clinical redesign working groups are removed.
But outcomes-based commissioning is not a panacea: it simply reframes system redesign to focus on collaboration between providers that, under an outcomes-based contract, are now working to the same stated aims. The negotiations between these providers, however, remain as circular as ever. Before hospital fixed costs can safely be removed, sufficient infrastructure must exist within the community for the care to be delivered there instead – but resourcing that infrastructure first requires funding to move out of acute hospitals.
This time, however, another party can break the deadlock: the patients themselves. With 21st Century technology and relatively little expenditure – indeed whether we like it or not – patients can access more information than ever before on health and healthcare. Using advice on self-management, comparisons of experiences at different providers, and information on the pros and cons of treatment options, patients make their own trade-offs between different modalities of care. Evidence and experience show that when such information is harnessed and used systematically and consistently, patient empowerment can lead to reduced demand for specialist care, different choices of providers of care – and improved outcomes.
So, if the power of patients’ knowledge makes system reconfiguration eventually inevitable, how can providers best respond? The roadmap to 5YFV’s nirvana includes three things:
- Skills and capability in population health management – not just risk stratification but segmentation, profiling and healthcare offered in the most appropriate format for each patient type
- Revised provider organizational strategy in the context of their offer to the whole system – stopping delivery of some service lines completely so that they can be provided at higher value elsewhere
- Knowledge and transparency about costs, with open-book accounting across the system and appropriate transfer of resources between providers
What stands in the way of this happening? The most common reasons are not related to regulation as some might imagine, but rather the sheer scale of trust, determination and altruism required between leaders of local providers. No wonder some health economies have tested the water first with smaller population cohorts (such as those needing musculoskeletal care as in Bedfordshire, Bexley, and Sussex) and catalysed the process through a prime provider model.
Co-operation between providers to deliver better value care has parallels with the development in the United States of ‘accountable care organisations’ (ACOs). In England, we have the advantages of established primary care, recognised inclusion of social care, and a national mandate between government and the NHS already using outcomes as its currency. As with ACOs, we are learning from pioneers in the field. But it feels a fragile concept – still too easy to dismiss when facing problems hard to solve.
It was said in the US that an ACO is like a unicorn: everyone knows what it looks like but no-one has ever seen one. If the 5YFV describes our NHS unicorn – integrated systems delivering better health through high value healthcare – then it is the responsibility of us all, patients, clinicians and leaders, to carefully nurture these fragile and valuable beasts out of dreams and into reality.
First published for Reform conference: The future of health: An integrated health and care system