Over the last year the idea of outcome based commissioning within the NHS has evolved from being a policy to establishing real contracts. In a little while a completely new provision for musculoskeletal (MSK) services will begin in Bedfordshire organised by a partnership of a local Foundation Trust (FT), an existing GP led MSK service, a private sector hospital group and patient charities. This partnership will replace a plethora of very different and fragmented contracts that are currently held by different organisations, each of which was contracted to provide fragmented care inputs.
It’s a big change, and the journey to establish outcome based contracts has been characterised by long periods of universal agreement punctuated by periods of intense conflict. Why has this happened?
Those with experience of working to change policy in the NHS will recognise that dangerous moment when everyone agrees that the new policy you are trying to create is correct.
It is the moment when you prepare… for nothing to happen. All sorts of people agree with a change in policy – because in the end no one cares about changes in NHS policy. What matters are the changes in NHS practice that will take place if a policy is implemented.
Unsurprisingly this has been true of the recent development of outcome based and integrated care contracts in the NHS. From 2010, with the development of the NHS outcomes framework followed by the Secretary of State’s mandates for NHS England, most policy has argued that the NHS should start judging itself on patient outcomes and not inputs.
At the level of policy few can disagree with that. Intellectually we know that money spent on a hip replacement operation only creates real value if the patient can resume work – or walk to visit their daughter without pain. The policy of paying for outcomes and not inputs must be correct at an individual, social and economic level.
Equally most policy makers are quite rightly concerned about the current fragmented care for the elderly. So it’s interesting that when you ask older people and their organisations what would count as a positive outcome for their care the answer is very simple.
“Since you spend so much money on our health and social care, what we would like is that every time we come into contact with the health or social care system, we are more independent at the end of an intervention than we are at the beginning”.
The individual social and economic outcome of greater independence must be a good thing and, if we could achieve it, surely worth the money that is spent on the service. As a goal it’s difficult to argue against.
But current provider practice is all about fragmented inputs. Moving to new, patient based, outcomes is very disruptive of current practice. The problem is that a great deal of existing practice produces the opposite outcome for older people in that it creates greater dependence. If the long term condition of an older person becomes exacerbated – resulting in a 12 day emergency admission to hospital – this hospitalisation will normally leave the patient with a higher level of dependence. If they move wards several time during their stay, they may even have increased experience of dementia and therefore substantially increased dependence.
A contract based on paying a provider only if they achieve greater independence for this older person would therefore need a very radical shift in practice. And it is here, at the point of implementing a policy of outcome based contracts, that the near universal agreement with the policy disappears. Providers recognise that in order to maintain financial sustainability they will need to radically change the way in which they operate.
It is at this stage that we are told that working to patient outcomes will destabilise the NHS.
And if we take that last sentence literally it is true. The current stability of much of the existing model of care from providers has evolved from the experience of fragmented care that many patients regard as normal. Integrated, outcome based, health and social care will destabilise these existing models of care – and that will be a good thing. .
Because policies really don’t matter if they aren’t implemented, and over this calendar year we will see whether the NHS and social care can bring about the change that comes from working towards outcomes.
In recent weeks Oxfordshire Clinical Commissioning Group (CCG) passed proposals for the CCG to work with existing providers to develop outcome based contracts for older people and mental health services. The CCG have now reached the point where they have to negotiate with existing providers the radical changes that working to outcomes will being.
By deciding to work with existing providers the CCG have demonstrated that the development of outcome based contracts does not have to involve market based procurements. The CCG recognises that existing providers may have the capability to radically reorder their priorities. But they have the option to hold an open market procurement for the roll-out of 2014-15 contracts should dialogue at the point of contract agreement not be successful.
As in Bedfordshire outcomes based contracts will necessitate new ways of working which will need new forms of provider partnership.
Elsewhere the movement is gaining widespread support with CCGs backing prime and alliance models of contracting, to change and challenge the commissioner/provider relationship where existing models simply don’t work. Along with Oxfordshire, other CCGs leading the way include Cambridgeshire, Bedfordshire, Bexley, Northumberland, Croydon, and Staffordshire.
In all of these locations and more, the crunch will come when the idea moves from being a policy to making the necessary changes in the practice of provision.