Why the NHS are dipping their toes into the outcomes-based commissioning pond

Why the NHS are dipping their toes into the outcomes-based commissioning pond

Thoughts from Cobic Founder and Chief Executive Nicholas Hicks on the King’s Fund Integrated Care Summit.

By Dr Nicholas Hicks, Chief Executive of Cobic, and former Chief Executive and Director of Public Health at Milton Keynes PCT.

Last week I spent an interesting day at the King’s Fund Integrated Care Summit. There were some excellent speakers including Chris Ham for a chair’s overview of integrated care, Andrew Ridley on some of the best of Better Care Fund plans and Rachael Addicott sharing early lessons from pioneering Accountable Care Organisations. The audience was hungry for ideas about how to improve the integration of care in their local patches. A consensus emerged throughout the day on a number of things, which impressed me; however there is still much confusion over what integrated care looks like, how to measure success or failure and more fundamentally, how it should be achieved.

Some of the positive themes that were discussed included:

  • The NHS requires payment reform at scale so that providers of care are rewarded for better outcomes rather than the volume of care they provide. This will create the conditions in which transformation and integration can take place.
  • The NHS needs providers to take on a population perspective. This probably means putting them at some degree of risk for population costs and population outcomes. The intention is that organisations and individual clinicians see themselves as responsible for improving outcomes for a population, and not just those individuals referred to them.
  • The desirable end point was generally seen as providers taking responsibility for whole (or broad groups) populations rather than for narrow segments of populations. This is to avoid replacing old silos with new silos.
  • Multi-year contracts give both security to providers and creates a strong incentive, plus encourages more investment in cost-effective prevention.
  • Initiatives designed to improve integration should start with consideration of clinical and service integration, rather than start with organisational integration – although organisational change may be required to support the delivery of the newly integrated care.

I found these important conclusions to be uplifting and exciting. They seem to me to offer a potentially constructive, sustainable and achievable vision for a 21st century NHS. They may also herald a change in the whole business model of health and social care, which, if achieved, would create the circumstances in which our health and care system can be re-built around the needs and wants of individuals, and the outcomes that matter most to them. This sounds like a goal worth striving for.

But alongside these positive and practical messages there were also some surprising areas of confusion, and I thought an unnecessarily downbeat mood coming from the academic and commentariat communities. For me the surprises included:

  • An inability of the academic community and policy commentariat to generate standard definitions of what is meant by integration.
  • A lack of clarity that integration is not an end in itself, but rather a means of delivering better outcomes for people and better value for the tax-payer.
  • A dearth of good advice about how to generate valid, relevant evidence about the impact of better service integration. It seems clear that more thought and academic leadership is required to define the measurable outcomes of integration and to design the studies to investigate initiatives.
  • A lack of ’system thinking’ in research studies. By this I mean that better integration seems to me to usually require multiple interventions in a health system and that we need to be looking at the impact of the combination of interventions as well as the impact of isolated specific interventions e.g. some places have introduced payment reform, risk stratification, multidisciplinary assessment, personalised care planning, and more. The impact on service integration results from the aggregate of all the interventions in a particular place. We need research studies that can explore the totality of the impact, as well as studies that seek to isolate the effectiveness of specifics intervention, many of which may be minimal in isolation but significant when combined with other elements of an integrated system of care.
  • A lack of a discussion about a route map of how to get from where we are today to the personalised and outcome-orientated population approach that everyone wants to see.

Failure to address the first three of these four points will slow progress towards integration and transformation, but will probably not prevent it. By contrast, failure to identify a practical way for people to begin to make progress is much more serious. For me, moving from where we are to a fully capitated outcome-incentivised system is the right goal – but it is a huge change. I doubt there are many places that can make that change in one step safely. More practical is an evolutionary (but still bold) approach.

And in my experience, this is seems to be what is emerging from the NHS. There is a growing appetite among both commissioners and providers to experiment with capitated outcomes-based incentivised contracts and to understand what it means for both the commissioning and provision of care. People want answers to questions such as: What are the skills and capabilities that are needed? What the risks and opportunities? What are the information requirements? How do we identify and measure the relevant outcomes? How should budgets be set?

The way people are choosing to develop answers to these questions and more is by dipping their toes carefully in the outcome-based commissioning pond. They are limiting risk and maximising learning by starting, not with whole populations, but segments of populations. For example in Milton Keynes they started with services for alcohol and substance misusers; in Bedfordshire and Sussex, with services for people with musculoskeletal problems; in Bexley for services for people with or at high risk of heart disease; in Oxfordshire for people with mental health problems; in Staffordshire for people at the ends of their lives and for people with cancer; and in Cambridgeshire and Peterborough for older people.

It seems to me that starting with a population segment is a good way to start and to learn. I very much doubt that any of the places listed above see the segmented population as their end point but rather as a bold and relatively safe way to start their journeys of transformation. There would, I think, be valid concern if these segments were regarded as endpoints – as there would be a risk of replacing one set of organisational-based silos with another set of population-segmented silos. And many individuals will have conditions that relate to different population segments, and yet need and want the system to treat them as a whole person and not as a series of problems.

I think there are several implications of all this. Firstly that it is increasingly recognised that we need to move to a capitated system of funding providers that reward their ability to improve the outcomes that matter to citizens. Secondly, there is recognition that this requires a huge change in the way the health and social cares system works – a change that probably needs to be introduced quickly but incrementally. Thirdly, that so far the pioneers on this journey are choosing to start by segmenting their population as a means of limiting risk, and as the starting point rather than as the endpoint of their transformative journeys. In the absence of other suggestions about how to begin a journey towards a capitated and outcome-orientated health and care system, we all need to think how we can support and learn from the pioneers so that together we can define the path (or paths) to the future that we all want to see.

COBIC – Capitated Outcome-Based Incentivised Commissioning – is a common sense approach to securing both value for money and better outcomes for patients. As a contracting approach, COBIC releases commissioning and providing organisations to get the best out of their responsibilities handed to them from the NHS reforms.