NHS reform will require new dialogue between GPs and specialists

The improvements now needed in patient care, combined with a £20bn efficiency gain, demand a renewed approach to how we deliver health services in the UK.

Jenny Shand: 'Moving towards integrated care will be a significant change'
Jenny Shand: 'Moving towards integrated care will be a significant change'

Achieving success will require a shift to a new focus on value: outcomes achieved for patients per pound spent.

The health secretary has reinforced this through the desire for the NHS to compete on quality and not price, to measure whole pathway outcomes and support for a new tariff system (year of care pathways). [1]

The development of GP consortia will ensure a dialogue between clinicians, particularly primary and secondary care, to ensure we can best meet combined objectives of delivering high quality care to patients.

The financial challenge not only creates the opportunity to organise around patient needs, but an imperative to do so. The core components of a value-based approach require organisation and delivery of services around the needs of patients, measuring outcomes and changing funding structures to align incentives across providers.

At our recent conference on Maximising Quality, Minimising Cost [4], Professor Michael Porter, from Harvard Business School [2,3], was well received by the audience of 550 healthcare leaders.  His messages were clear:

  • ‘Cost is not the goal’ - It’s about outcomes for patients.
  • ‘We have to organise around the patient and their set of needs’ - Join up care across professional and institutional boundaries.
  • ‘Measure outcomes for every patient’ - Align all providers around the group of measures, the common goals, that we are collectively accountable for delivering
  • ‘Pay differently’ - Bundle payment for the full care of a patient’s medical problem rather than for individual services.
  • ‘Create an enabling IT platform’ - Use universal data definitions, interoperability, and create a mechanism to easily extract outcome, process, and costing measures from all providers in the system.
  • ‘Expand based on excellence’ - Ensure that care is delivered by organisations which have the appropriate scale to deliver excellent care efficiently.


So, if we agree that value is the goal, how do we get there and how can we accelerate progress? The task is not straightforward but already pockets of activity are demonstrating that it is achievable when approached on a medical condition level.

Moving towards integrated care will be a significant change for any healthcare economy that has evolved with institutional boundaries and has been subject to the mixed incentives that have driven divide rather than union.

Most change programmes fail, and most of those failures arise from cultural factors. If an integrated approach to care is to succeed, strong leadership needs to be in place to build the support necessary to deliver the vision. This can be reinforced by the process and structures of the system.

Despite an explicit focus on quality and cost improvement, traditional ways of working need to change if we are to accelerate the pace of change. Specific actions can help put in place value-based healthcare:

  1. Become role models for the change we seek, not for the status quo: Everyone from across the system can begin to behave in a value orientated way. Committing to specific actions and demonstrating what change looks like is one form of role modelling. Finding opportunities on our doorstep can be relatively small to have a large impact.
  2. Foster understanding and belief: Ensure the people around you know what is expected of them, agree with it and think it is meaningful. Goals in terms of measuring outcomes for patients in specific conditions will need to come from within. It is about clinicians leading a process of transforming clinical care. 
  3. Reinforce with formal mechanisms: Develop structures, processes, and systems to reinforce the change in behaviour that is required. Ultimately we need an electronic record owned by the patient, performance discussions focused on value, and payment systems that reinforce the desired model.
  4. Develop skills and capabilities: We need to be equipped to work in this new environment. Education reform will be fundamental to ensure that the clinicians are being trained for tomorrow’s world rather than the current state. We need to review the full spectrum of education.

At the conference it was clear that there are specific actions we can take now to ensure we reshape how we deliver care in the NHS and achieve the value orientation for patients and the populations we serve.

David Fish, managing director of UCL Partners, committed to three specific actions – to measure outcomes, to support leadership development, and to hold a two-day course with Michael Porter to explore the next level of detail on how we ensure we deliver value in practice.

We all need to do the same, to look at our day jobs and think – what can I personally do differently tomorrow that will get us one step closer to a value-based system?

As Professor Porter said: ‘If we can actually put some of these ideas into practice, have the courage to move ahead in these directions, along these general principles, there is the opportunity for the UK to become the global leader in value-based healthcare delivery’.

Jenny Shand is director of integrated care at UCL Partners.

1. GPonline.com. Video: Lansley responds to critics of NHS reforms. 2011 [2 February 2011].
2. Porter ME. What is value in health care? N Engl J Med. 2010 Dec 23;363(26):2477-81.
3. Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston, Mass.: Harvard Business School Press; 2006.
4. UCL Partners, Monitor. Maximising Quality, Minimising Cost: The concept of value for money in healthcare and the importance of clinical leadership 2011, 24 January 2011; The Mermaid Conference Centre, Blackfriars, London.

Further reading

  • Lee TH. Putting the value framework to work. N Engl J Med. [Comment]. 2010 Dec 23;363(26):2481-3.
  • Mountford J, Davie C. Toward an outcomes-based health care system: a view from the United Kingdom. Jama. 2010 Dec 1;304(21):2407-8.

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