As a nation we probably have the best information on health care in the world.
Data on service use, cost, and increasingly quality, across the whole population and for some years, and large chunks of it available at person-level (suitably anonymised) and linkable wherever the patient receives care.
Useable to track costs, assess substitution of care, stratify the population by risk, track cohorts of patients through time, assess impact of interventions, spot good quality and efficient care, develop business cases for invest to save innovations, shape clinical behaviour, develop payment currencies – to name just a few options.
Utilisation or encounter data are well established at person-level through HES (Hospital Episode Statistics), and the (hopefully) soon-to-be available data from GP clinical systems (under the GP Extraction Service or GPES).
Cost data are generally not available at person-level, but estimates can be made using the tariff or reference costs.
But the Department of Health estimates that about 60 per cent of hospitals now have some kind of patient-level information costing system (PLICS) where actual costs per actual patient can be derived.
Our recent report on the subject showed the power of PLICS to demonstrate fruity variations in cost between apparently similar patients treated by different clinical teams. And, at our example hospital, only 17 per cent of tariff-chargeable cases incurred costs within 10 per cent of their tariff price.
And patient-level information on quality that could be linked to patient-level costs? Here there is room to develop and dock with the medical world of clinical audit.
Professor Staffan Lindblad from The Karolinska Institute in Sweden recently described to us in a video interview, his pioneering work in rheumatology using patients to enter regularly and online their health status information, and then to use predictive modelling techniques to assess the impact of certain treatment regimens.
Almost all specialists and 80 per cent of rheumatological patients take part, and daily downloads of information across Sweden mean that the up-to-date impact of various mixes of drugs can be assessed on patients by risk type. The result: tailored treatment for individuals and a 50 per cent reduction in joint inflammation for patients over a decade.
In Sweden, clinical audit like this developed bottom-up starting with patients. In the NHS, it has been rather more top-down – for performance management purposes – and thus less focused on individual patients.
There is a lot of developing to do to get to the Swedish level of detail and innovation in clinical databases. But linking the patient-level clinical data on outcomes Swedish-style with costs would be a small step beyond.
Then we can get much closer to assessing value at patient level and really engage the medics. We are going down this path, but now is the time if any to speed up.
A few other new bits from Nuffield Trust – reflections on what clinical commissioning groups (CCGs) can learn from independent practitioner associations (IPAs) in New Zealand has just been published. New Zealand IPAs have been around for some years but how they have managed to develop into cohesive collective entities may be useful for CCGs or groups of practices wanting to federate/collectivise as providers.
And thanks for all the positive feedback we’ve received on our new interactive timeline of NHS reform going back to the inception of the service – do have a look if you haven’t seen it already. We will update this resource with the latest reforms on an ongoing basis.
Dixon J (2012) ‘Exploiting the single payer inheritance’. Nuffield Trust comment, 28 September 2012. https://www.nuffieldtrust.org.uk/news-item/exploiting-the-single-payer-inheritance