The challenge to deliver five extra years of healthy productive life in England is far more likely to succeed if the financial metrics that drive health and care are also aligned in mainstream practice.
The factors that will drive and accelerate healthy productive ageing are multifactorial and lie within and without the present health and care systems. Within the healthcare continuum, the financial metrics that drive the NHS also need to adapt and change to the new reality of making prevention of disease and maintenance of healthy productivity of the citizen a core key outcome.
The transformation of the current NHS is further fuelled by an increased understanding that health and care need to deliver more productivity per unit cost and also deliver service with measurable improvements in outcomes, rather than solely in activity, for citizens. Furthermore, they are driven by the long-term unaffordability of the present models of delivery, exacerbated by ageing and multi-morbidity of citizens.
Patient-centred care delivery
To accomplish this reimagined new health and care system, a holistic view of the individual, including the non-health determinants, needs to be captured in the design of patient-centred care delivery and the fact that the only real option for delivering this is via digital transformation offers a real opportunity to capture appropriate data points to drive and monitor the new system.
There is emerging consensus internationally that new health and care systems need to be capitated, personalised, and value and population-based. From Europe to the Americas to the Middle and Far East, systems are in transition to new models of care. These new capitated models are favoured by payers in that they seem to offer better financial control, as well as offering advantages over the existing activity-based models, as they tend to value long-term individual outcome above units of activity as well as truly incentivise the prevention of ill health and the promotion of well-being.
No simple solution
Managing health and care systems is particularly complex. As live, complex, adaptive systems, they are made up of myriad moving parts and the probability of producing unexpected consequences through tinkering of a few sentinel metrics is high.
Outcome metrics are not an exact science and we are in the foothills of our understanding of how best to drive them. There is no simple formula and the fact that one outcome inevitably affects another makes the design of metrics particularly challenging, which is why they are a continuous work in progress.
Using financial metrics to encourage health care systems to shift their emphasis from activity to outcome cannot occur in a single step without significantly increasing the already considerable pressure on delivery systems, but is achievable by a more nuanced and staged approach.
Thus, an approach which may be worth considering is utilising a process which encourages the transition to a more preventative population health-based to be effected over a number of years. Whilst there could well be debate around the pace this change needs to be effected over, and the percentages which need to be allocated to prevention as against activity, the most pressing action now is stating this will be the direction of travel the NHS will be taking for the foreseeable future as what would immediately benefit the NHS is purposefully stating that a shift in the financial metrics from the present activity-based ones is being made as part of its long-term plan, and describing the optimal end state as one which would encompass both activity and outcome.
With such a complex delivery system made up of a multitude of players, all working through the fundamental shifts associated with digital transformation, changes in processes (like enabling interoperability and streamlining activities) also need to be encompassed in order to deliver financial predictability, enabling payments to be normalised on a year to year basis. The optimal approach must encompass the capitated, personalised, value and population-based systems we aspire to deliver in the pursuit of universal health care provision, and thus include both personalised outcome measures as well as activity and progress indicators.
The NHS’ approach
The NHS by 2030 will be deployed onto a population which may well be very different to the one today. It will have become older and with the advent of a more personalised public health offering to individuals via precision health and enabled digital connectivity, the citizen will be much more activated.
When the NHS five-year view was published in October 2014, what was presented was a vision not a plan. The assumption was that the plan would immediately be followed by the details around implementing outcome-based population based financial drivers. The same could be said for the NHS long-term plan published in January 2019, where there is promise, but no timescales as to how the payment systems are to be altered and at what pace.
The NHS in England has to balance the loosening of its centralist culture and make its offerings fit the various diverse demographies it serves, and do this in practice, whilst remaining a corporate national body. The historical approach that it has perfected, to drive the system through metrics which look to assure a national agenda over a local one, inevitably will lead to metrics and subsequent delivery of care which are an approximate fit everywhere and a perfect fit nowhere.
In terms of deployment, what could be achievable without destabilising existing provision would be a cumulative substitution of an increasing percentage over the first three years. This would achieve the 25% change of the existing activity metrics which drive the system to achieve the changes required. Thus, in the case of the total core income for NHS hospitals, 5% in year one, 7.5% in year 2 and 12.5% change in year three would achieve the first major step by having a quarter of all the financial drivers pointing towards prevention. As regards to primary care, the same pace and methodology would apply. In this case, the challenge is selecting metrics which are relevant to the served population. The adoption of primary care networks, with their populations of at least around 40,000 makes this more achievable.
The new outcome-based metrics to drive prevention and better outcomes could be developed over a period of years in an iterative process.
Whatever the metrics selected, the overriding factors to be taken into consideration are the life course approach as well as adoption of newer concepts like HealthSpan.
Charles Alessi is chief clinical officer at HIMSS International. Healthcare IT News is a HIMSS Media publication.
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