The mechanisms for change
The momentum for change will come from the staged introduction of demand-side mechanisms. These will pull through fruitful reform that forces the alignment of the system to the needs of the patient or citizen. This will confront the failure of supply-side inertia.
High quality information on outcomes
The emphasis on outcomes and information is the first step in productive reform. It moves attention away from big reorganisations and small politics. It focuses everyone’s minds on doing what is right for the patient. It is imperative that high quality information is made available to providers and consumers about which health and social care treatments and interventions work best for the individual (in terms of outcomes), the taxpayer (in terms of cost effectiveness), and the system (allowing it to learn and to innovate).
The data that such a shift will generate will be a major boost to the accumulation of learning and the spread of best practice. There is a tendency in any job for people to do what they have always done, in which case the work becomes task-driven and not outcome-oriented and patient/consumer-attuned. The process of enquiring into what works best and learning from others in the profession is expedited by this change from task- to outcome orientation.
Guided choice is the process whereby UK citizens can choose to go to the best provider of health and social care outcomes rather than the only provider. The combination of well-publicised outcome data and the exercise of choice is a potent driver of change. To use an international example, there are 139 transplant facilities in the United States. The best of these transplant facilities is excellent – and has a 100 per cent one-year, risk-adjusted survival rate39. The worst facility has a 1 per cent one-year, risk-adjusted survival rate. It is clear what a citizen armed with information and a vote will do in these circumstances, and how that behaviour will take menacingly poor practice out of operation and animate the spread of best practice.
Making the money follow the patient
Personal budgets, whereby people are given the money to which they are entitled and are able to spend it on the best provider, are now widely used and successful in social care. In the NHS currently, flows of money are to the same institutions – mostly hospitals and GP practices – as they were in 1948. There will be very limited reorientation of those services, then, until the money follows the patient.
Competition and the private sector, when applied to the NHS, have become toxic words. However, competition is vital if we are to get a service that provides the best care for people in the UK. The issue of the private sector is a red herring. Much of the competition to earn the right to deliver a service will actually occur in the public sector. Take, for instance, Great Ormond Street, which delivers the best paediatric care in the country (perhaps even in the world). If it can deliver better care than the paediatric units in other UK hospitals then why shouldn’t it take on responsibility for those units?
Individual guided choice can only go so far in reforming the system. Commissioners create the market landscape within which consumers can exercise their choice. It is the commissioners’ knowledge of pathways, and their analysis of what produces the best outcomes, that creates the services that users/patients access. Commissioners then make that information available to everyone.
Commissioning will increasingly be based on a virtuous circle that identifies the best treatments, collects information to test outcomes and then adjusts the treatment regime accordingly. Commissioners ensure that all services are put out to tender regularly – in natural monopolies – or that sufficient competition is maintained to keep organisations honest.
They will manage economies of scale (building deep competence in treating specific medical conditions) and scope (taking this greater and safer competence to all parts of the country) in the interests of patients. Commissioners make sure that market failure does not interrupt service to the public.