The underpinning financial drivers of the NHS destabilise it. Payment by Results (PbR) activity drives hospitals to suck in patients while GP commissioning tries to keep them out.
This is a pointless confrontational process that reduces commissioners’ ability to control activity in their patch of the NHS.
Here is a new way of doing business called ‘co-operative commissioning'. This is one of a number of ways of redesigning financial incentives that maximise cooperation and ‘upstream’ working. It is based on the idea of programme budgeting on which every PCT reports and which shows the spend on clinical areas, such as cardiology or orthopaedics.
Instead of investment on the level of a hospital or drug budget, the focus switches to specific health objectives such as reducing the incidence of type 2 diabetes, reducing death rates from heart disease, improving indicators of child health, reducing the burden on family carers of patients with senile dementia, and so on. The ultimate aim is to maximise health gain by deploying the available resources to best effect.
PbR in an area such as Lewisham PCT is suspended and a ‘joint account’ between primary and secondary care along a pathway – cardiology, say – is created. We know roughly what is spent on cardiology through programme budgeting and make this the spend envelope within which all work has to be done.
If savings are made in that envelope, they will get reinvested in the pathway.
Such joint (not pooled) budgets would be allocated virtually across primary and secondary care along care pathways, based on a programme budget approach.
The task of consortia, local people and hospitals then becomes to manage a joint budget so that it maximises efficiencies and patient care. The incentive for everyone is that savings can be reinvested in the pathway, or elsewhere, as agreed.
Hospitals involved in this process would still risk losing income, but there would be two routes that offer relief: savings can be reinvested; and, if the hospital also runs community services, it would benefit from any shift in that direction.
Taking diabetes as an example, cooperative commissioning would involve clinicians and patients working together to come up with the best solutions. The commissioners’ role therefore would be to:
- Set the parameters and outcomes and quality. For instance, we would expect a reduction in A&E attendances, a reduction in admissions from A&E, an increase in patients reporting they had received good quality information and were treated with dignity. How this is achieved would be up to the diabetic panel.
- Refuse payment for poor outcomes. These, for example, amputations or retinopathy would be specified in advance.
- Insist on appropriate data (patient level information and Costing Systems)
- Ensure patient and public involvement.
- Include pharmacy
- Describe the funding envelope
- Reduce the funding envelope by 2% in the first year and again by 2% in the next.
- Project manage the process
- Manage financial and practical risk.
The spend would be seen as belonging to both primary care and the hospital and may be to social care and health. If savings were made through more efficient care pathway design, the savings would be shared.
If fewer patients came through the hospital’s doors, the hospital would still gain if savings were made. It would become a joint task to ensure patients received treatment in the most cost-effective way.
For many LTCs there are evidence-based interventions that reduce outpatient and A&E attendance, including information provision for self-care management and prevention. There would now be an incentive for hospitals to invest in these.
There may be more enthusiasm for cooperation in A&E as savings there would mean more joint benefit.
In this way, incentives for efficient care are retained, but the planning and investment becomes a shared enterprise. My prediction is that NHS staff will leap at this chance to work together again in a shared enterprise. Complexities include dealing with more than one hospital.
The end result may remain the same but many disciplines in the hospital will still need to bite the bullet of losing services to the community. Other hurdles are including social care ad health, agreeing a joint budget and ensuring the consortium oversees the process but does not determining the outcome.
Co-operative commissioning would improve the NHS at a stroke.
- Dr Fisher is the patient and public involvement lead for the NHS Alliance