Following on from this month’s activities where we assembled as a group of stakeholders to collaborate on a bid for the governments Industrial Strategy Grand Challenge for Healthy Ageing, I started to think about how we are delivering (and, perhaps more often, not delivering) a holistic service to our citizens.
It seems apt to pull this thread given the latest reorganisation that has been announced by NHS England; from CCGs to STPs to ACOs (to briefly ACSs) and now ICSs (Integrated Care Systems), and that is only since 2010. Confused? You’re not the only one. Irrespective of the nomenclature of this latest reorganisation, the general gist is that NHS England and the powers that be have indeed seen the light. The focus for the ICS is to move away from the historical ‘Hospital Based Model of Care’ to delivering more care in the community: instead of reactively managing disease, proactively promoting health and wellbeing. Simon Stevens’ 5 Year Forward Plan originally set the scene whilst the NHS New Care Models Programme tested the waters. We’re now in a position where the first of these new ICS have been up and running for a year or so and early reports suggest encouraging results.
Individual ICS are operating as independent, autonomous agents and information on how they have organised their models for financial remuneration isn’t easily accessible. The likelihood however, is that they are operating with a Capitated Budget system, which appears to be the preferred choice for NHS England. Whereas the existing system for many provider organisations was pay per service through the national tariff program, which quite often leads to tunnel vision and a lack of appreciation for the wider system that surrounds an individual patient, the Capitated Budget may overcome this as a provider has a fixed budget from which they must provide healthcare for an individual. The hope is that providers will look to spend money on services which span traditional organisational boundaries (previously barriers) to produce the greatest value (eg preventative care).
If we look at the concept of ‘Value’ in healthcare, most definitions centre around achieving the best outcomes for the lowest cost. However, in publicly funded healthcare systems like the NHS, the word 'Value' has a slightly broader definition, not only is it about achieving the best outcomes for the least cost they must also take into consideration how resources are distributed to the population they serve, to achieve the best overall outcomes for the good of the nation, as well as aligning outcomes to the values of the individual (ie what actually matters to patients?). NHS RightCare was in fact set up to tackle such issues (Figure 1).
Figure 1 (NHS RightCare definitions)
Prof Michael Porter, a renowned thought leader on Value Based Health Care, disagrees with the Capitated payment structure. He argues that Capitation rewards providers for spending less but not necessarily improving outcomes. One could argue that provider organisations that skimp on care and don’t improve outcomes, leave themselves open to additional costs in the long-term from poorly managed patients and therefore Capitated budgets, when properly thought out with long term strategy could work. However, it is easy for me to see how providers could cut corners with the Capitated payment structure and choose to ration certain services, particularly for patient groups that aren’t well represented or particularly captured by nationally driven targets or incentive schemes. I should also point out that, payment-by-results schemes are widespread within the NHS (remember CQUIN and QOF), so it’s not as though we haven’t tried this model. But I’m equally sure that many of us within the system realised that this soon became a tick-box affair and we were being rewarded for Processes (“Have you checked smoking status?”) and not necessarily Outcomes (“Rates of Smoking Cessation”).
Prof Porter and his team have gone on to define the ‘Value Agenda,’ a series of six crucial components that are interdependent and mutually reinforcing (Figure 2).
Figure 2 (The 'Value Agenda')
Though it is beyond the scope of this article to analyse each point in depth, especially when the Harvard Business Review has done a far better job than I ever could. I focus on that which captured my interest, particularly around the work we are currently doing with user-centred design and technology.
‘Measuring outcomes and costs for every patient,’ though this sounds like a reasonable expectation of our healthcare service it may surprise you to learn that this is rarely done at an individual level. Certain specialties, particularly surgery and critical care are fastidious at recording outcomes though this is largely driven by national reporting (as seen in Cardiothoracic surgery) or for research purposes (as seen in Critical Care). Irrespective of the driving force behind this, the act of measuring (and publishing) one’s performance is in itself a powerful motivator for improving quality and standards. Something that is ripe for disruption however, is in choosing which outcomes we’re measuring. Many of the ‘quality metrics’ we record are crude indicators of quality (mortality, complication rates, lengths of stay, etc). Though these are of course very important, by focusing on just these we risk losing sight of what’s important to patients. These ‘patient-centred-outcomes’ are going to grow in importance as we transition towards more of healthcare at home model, where we expect patients to self-manage and to take an equal partnership in managing their condition. If mortality stats are what motivates surgeons and hospitals, then it’ll be Quality of Life metrics that motivate patients. The looming Digital Revolution will facilitate this of course, patients inputting pain scores into their iPads after a knee-replacement isn’t so farfetched. Soon we'll find we have a wealth of outcome measures easily collected and readily analysed.
Whilst I have found myself largely agreeing with many of the pillars of the ‘Value Agenda,’ I did wonder if it had missed a trick. Was this not the perfect opportunity to throw off some of the shackles of the Industrial Healthcare Complex and instead explore models for a more personalised, holistic service? Understanding outcomes which are important to patients is key to this; for any organisation looking to implement value-based healthcare, should they not also look at that which is valued by patients? This may mean patients preferring to travel shorter distances to be treated at their local hospital in spite of the knowledge that they’re sacrificing quality or it might mean a patient chooses to forego the first line, most effective treatment option as the side-effect profile is unacceptable for their particular circumstances. What we’re really getting at is the issue of shared decision making, which is quite often sacrificed in the blind pursuit of quality improvement and cost-saving (standardised treatments, one-size-fits-all, economies-of-scale...you get the picture). Yet we know that shared decision making often results in a reduction in healthcare utilisation and above all, isn’t it the most ethical way for us to continue delivering healthcare? Movements like the Choosing Wisely campaign have now become mainstream and make it easier for clinicians and patients alike to make decisions but individual organisations need to champion this for it to really take hold and become embedded in routine practice.
Whilst the ‘Value Agenda’ challenges the status quo which is in much need of change, I caution the slide towards further industrialisation of healthcare without consideration for the things that make a healthcare system humane.