A nicer challenge for 2012?

Blog post

Published: 16/12/2011

OK, so everyone is fed up with the Bill, just getting on with it, and focusing on having a break. But here are a few things from us to ponder at the end of this unusual year.

Ideological tussles will not go away next year. Alan Garber, now Provost at Harvard and our Rock Carling fellow this year, focuses his gimlet eye on one battle line: what place for competition, what dose, what unit of, and how could it encourage integrated care rather than get in the way.

Alan brings together his long experience of analysis in the US, and his understanding of our ‘culture’ and values to produce sharp insights in his Viewpoint publication: Competition, integration and incentives: the quest for efficiency in the English NHS. For any reflective person bothered about the NHS, it’s a must read.

Tom Frusher, employee of the NHS Cooperation and Competition Panel, is currently out in the US on a Harkness Fellowship looking at these issues with the Federal Trade Commission and Department of Justice – see his latest blog.

If practices or clinical commissioning groups (CCGs) are to be able to manage financial risk, they need as accurate a budget as possible.  Because of new advances in data linkage, we’ve produced a formula that sweats routinely collected person-level data and is highly predictive of next year’s costs for practices and CCGs.

Most of you are not anoraks, so we’ve made the dry topic of resource allocation easy in our new research summary and animation. And the formula also allows us, for the first time in the NHS, to assess empirically where commissioners might be under or overspending due to chance variation in demand.  This is critical to justify the right level of subsidies (bungs) for overspenders. More on this from us early next year.

Perhaps you’ve had enough of stuff on commissioning for one year.  But David Colin-Thomé (DCT to his friends) is always good value on this. See his guest blog.

Lots of talk about reconfiguration/closures at present, with nice reports from The King’s Fund amongst others.  It strikes me that public (and political) concern about these should focus instead on the NHS offer in an area i.e. coverage (insurance) rather than services (providers).

What might help is some normative framework of access/quality for what the NHS offer is, based on evidence.  For example, for this or that emergency, what is the maximum distance a person should travel to be safe?  What volume of service in a provider produces the best outcomes? If providers have social objectives (high quality and equitable care) as well as financial (should break even at least), such a framework might also help justify price subsidies that Monitor will have to work out if a provider can’t break even.

If done right, this framework could help cool unnecessarily heated public/political/clinical arguments, akin to the job NICE has done for drugs. I am thinking of a branch of NICE to take on this role: perhaps the National Institute of Clinical Excellence for Reconfiguration (NICER)?

On a related theme, in Germany there is the Payment by Results Commissioning for Quality and Innovation framework (PbR CQUIN) – like penalties for hospitals which do not reach minimum volume thresholds, where there is evidence that a certain volume is best for clinical outcomes.  This was spotted in the excellent book edited by Reinhard Busse et al on developments of diagnosis related groups (DRGs) across Europe.  OK, I should get out more.

Finally, we’re busy evaluating a range of out of hospital interventions and their impact on hospital activity and costs.  In this suite is included: the telehealth/telecare ‘whole system demonstrators’ ; the DH-funded integrated care pilots; NW London integrated care pilots; and a range of ‘virtual wards’ (see Lorraine Wright’s latest blog). In the spring we’ll be publishing a glut of material on this so keep your eyes peeled.

So rest up, be merry, try to forget about health care for a little, and come back restored on the other side.  A happy Christmas from us all at the Trust.

Suggested citation

Dixon J (2011) ‘A nicer challenge for 2012?’. Nuffield Trust comment, 16 December 2011. https://www.nuffieldtrust.org.uk/news-item/a-nicer-challenge-for-2012