Last week, Professor Michael Porter, was the key note speaker at an influential conference organised by Reform. His opening remark that the NHS has the potential to be a world leader in developing value based healthcare, set the tone for a enervating conference.
He argued that there is no healthcare system that isn't struggling but many are generating ideas and solutions - “same ingredients but different recipes” - and that there is an enormous amount that we can learn from each other. With that in mind, he set four challenges for the NHS.
The first was the need to identify the capacity to deliver a new healthcare vision and to define exactly what it should be delivering. He noted that the NHS is under the microscope as never before and that there was a need for someone or something thing to bring strategic coherence to the health economy. He noted that hospitals have to be coherent and cohesive but there are limits to what they can achieve alone and that horizontal integration can be highly effective. He recognised, however, that charges of anti-competitiveness had damaged plans for more horizontal integration and was concerned that Clinical Commissioning Groups (CCGs) might be too small and under- powered to effect the changes that are needed.
His second challenge was that CCGs need to be brave and lead on clinical reform and need clarity on what high quality care looks like. The third challenge was the urgent need for a solution to integration - a stubborn issue that has defeated successive governments for more than 30 years but one that he believes may finally have its moment in the sun. He also emphasised that it’s definitely not about structures but about incentives and enablers – in particular having an effective IT infrastructure and the need to resolve tensions between integration and competition. His fourth and final challenge was the need to improve the degree to which people manage their own care and to accept the importance of truly empowering patients.
Professor Porter argued convincingly that the NHS has many “structural assets” such as universal coverage and a single paymaster which gives it a real advantage over other healthcare systems. He then shared his suggested solutions to the above challenges, organised around six key pillars:
- Organise primary care into integrated practice units where care delivery is based on segmentation of the population and organised to meet the needs of the different groups. For example adopting a new philosophy for frail elderly people who need quick access to multi professional teams will mean practices becoming bigger and employing a wider range of professional skills.
- Measure outcomes (and not simply patient experience) combined with robust information on costs - and that determining a health outcome involves understanding the hierarchy of clinical and functional outcomes including time to recovery and sustainability.
- Reform payments to reward cycles of care – using patient level costing derived from activity based costing tools underpinned by a move to bundled payments for care cycles.
- Organise the system to deliver volume and address fragmentation - accepting the overwhelming evidence that excellence involves combining expertise and volume – and means stopping clinicians from doing things if they haven’t done enough to meet a minimum volume. It will also require helping patients understand that volume improves practice.
- Encourage excellent providers to expand geographically and for specialists to extend their geographic reach using a hub and spoke model.
- Build an enabling IT platform to support all of the above.
Given these ideas are already at the heart of the current debate in the UK the remaining speakers largely agreed on the direction of travel. Most described the need for co-ordinating care around the needs of patients, linking up health and social care and engaging patients as co-producers. There was a strong consensus that “outcomes” needed to be broader than “clinical outcomes” and the patient’s view of their experience was important in understanding the value of care, indeed that for end of life care the experience was the outcome!
It was widely accepted that integration is more than structures but is about aligning incentives and building teams with a common purpose. Moreover, that a more “sophisticated conversation” is needed on the role of competition and that patient choice should drive this conversation. Professor Robert Harris identified the importance of innovation and risk taking but that if an initiative fails that it should “fail fast with lessons learned”. He noted that the NHS has been a fair weather friend to industry and that if the NHS is finally to deliver value for money, there needs to be new types of partnership between the public and private sector, based on shared risk taking.
On reflection, I was left with the thought that the game changer will not be the type of health reform that is needed but how it will be achieved and importantly how patient-centered and coordinated it will be. Alan Milburn MP commented that a key skill missing from NHS science is public engagement and empowerment which are essential if the value agenda is to be finally delivered. While there was a sense that politics had obstructed reforms to local services in the past, there was now a greater degree of optimism that a more positive role for politicians is emerging to help reform services. Which only time will tell!
The slides from Professor Porter’s presentation are available here.