Pursuing nirvana

At last! We found evidence of an intervention which improves quality and reduces hospital costs. Is it telehealth? No! Is it greater competition? No!

It is care by Marie Curie at the end of life. People receiving the home-based Marie Curie Nursing Service were more likely than matched patients to die at home, according to their wishes, rather than in hospitals, and less likely to have unplanned hospital care.

This was our first excursion into examining the impact of home-based care from the 'third' sector – hopefully the first of many.

On competition in the NHS, here's an interesting paradox. Our recent study with the Institute for Fiscal Studies looked at changes in flows of patients across England since the introduction of choice policies in 2006 and the increase in independent sector treatment centres (ISTCs) providing elective care to NHS-funded patients.

For me, two headline results stood out.

First, the proportion of patients attending their nearest trust for elective care decreased, the proportion attending ISTCs increased, and the proportion attending their non-nearest NHS trust stayed about the same. OK – people are choosing ISTCs for treatment.

But second, the volume of cases being treated in each group of provider increased. If competition from ISTCs was designed to 'hurt' NHS trusts by taking business away from them, the competitive signal must have been surely blunted.

The paradox might be that in a time of growth in NHS resources, ISTC capacity increases and increasing volumes for all may dull any impact policy makers hope competition may have on NHS providers to up their performance.

And in a financial squeeze? Let's see what will happen. More potential competition for patients, yet will ISTCs melt away as the going gets tougher and tariff prices are held down possibly also through risk adjusted prices (if Monitor pursues this path)?

Who would have thought that competitive effects of this sort would be so difficult to generate?

The debate still rages about the impact of telehealth. Our results earlier this year suggest proceed with caution. Do not bet the farm on it to squeeze out much efficiency, at least in a world where telehealth may be used in a context of ‘usual NHS care’. Really to get impact, the context may need to change.

And integrated care: I agree with Norman Lamb. Let’s have some more radical experiments carefully designed, with proper ongoing formative evaluation and technical assistance to give oomph.

We need to give it our best shot this time. Sure, let the NHS have a go more widely, but I am worried the results (as before) might be similar as for telehealth without more care.

What of the Mandate? It could be bold and is worth a try. Let's see if it really can, as advertised, keep the NHS Commissioning Board at arms length from the Department.