Summer fun and international learning on health care reform

Blog post

Published: 17/08/2011

In the welcome breather from discussions over the Health and Social Care Bill, Nuffield Trusters have had a distinctly international flavour to our work. Professor Alan Garber, soon to be Provost at Harvard, gave our Rock Carling lecture examining how competition can coexist with developing integrated care. 

In the Q&A he gave some provocative responses: don’t rule out all forms of price competition for clinical care; and give GPs some direct (i.e. personal income) incentives for commissioning well.  For more details, watch a video interview with Professor Garber or listen again to his lecture, and don’t miss his full analysis to be published this autumn on our website.

In our annual US/UK bilateral organised with the Commonwealth Fund we chewed the cud on the respective reform proposals. For me there were three main points of learning for us. 

First, the plans to develop accountable care organisations (see Professor David Blumenthal explain this), in particular the calculus on how much shared savings (and financial risk) is appropriate.  I’ve always wondered how the financial physiology really works within Kaiser Permanente and quizzed Dr Francis J. Crosson (former Kaiser chief) at length on this in a recent interview. 

Second, experiments in reforming payment mechanisms to enhance better quality care – for example, bundled pricing of clinical pathways and payments for ‘meaningful use’ of IT. 

Third, I am always wowed by the emphasis in the US on detailed demonstration projects with pukka evaluation, even if demonstration is a substitute for reform. The Affordable Care Act allows for Centers for Medicare and Medicaid to set up an ‘Innovation Center’ to test innovative care and payment models rapidly and scale up successful models. The NHS Commissioning Board (now NHS England) should add this type of brain to its brawn. 

Squabbles on competition show no sign of abating over the summer with the publication of Zack Cooper and colleagues’s fine study in the Economic Journal examining the impact of competition between hospitals and quality of care in England. 

But while I can be persuaded of the association between competition and a reduction of in-hospital mortality rates, evidence on causation needs further work to convince. And for those of you who should get out more, the latest CCP’s report makes ticklish reading. My colleague Ruth Thorlby’s blog notes ‘a litany of infringements, dodges and liberties taken by PCT commissioners’ with respect to providing patients a free choice under the ‘any willing provider’ policy. 

How competition regulation in the UK and US can be shaped to allow meaningful vertical integration between providers will be explored in an international conference we are holding with Monitor on 12 September – see here for more details.

OK, OK, international is not just the US.  Guest blogger John Macaskill-Smith, a GP in New Zealand, tells us how networks of GPs down under have grown and developed and Cathy O’Malley helps to illustrate.

This all heralds a publication in the autumn here (with seminar attached) on the development of Independent Practitioner Associations in New Zealand and lessons for emerging Clinical Commissioning Groups. Keep your eyes peeled on this site.

And finally, anoraks corner. You know how much we like risk prediction tools here. Well we held a risk ‘fest’ in June with international speakers to explore the scene and what the NHS could learn. Professor Ian Duncan from Santa Barbara introduces the concept of risk adjustment and its application in health care. Dr Dirk Göpffarth explains how it is used in Germany to provide an empirical basis for financial bungs to insurers (lessons for the NHS Commissioning Board). Professor Wyn van de Ven shows its application in the Netherlands.

This was soon followed by the Department of Health’s recent announcement that it will not be commissioning a national upgrade of two statistical models that have been used in the NHS since 2006 to predict future hospital admissions – the Patients at Risk of Re-hospitalisation (PARR) and the Combined Predictive Model (CPM). My colleague Dr Geraint Lewis' blog provides the background.

These predictive models were funded by the DH in part to make free models available for primary care trusts (PCTs) to choose.  We believe that in addition to commercial software solutions, it’s important that there be a low cost or free option available to the NHS in future.  There are advantages for the NHS Commissioning Board and others in the health service in being able to access such a standard model so we will be exploring a range of models that might be needed in future. 

This is an important area of development and one that is rapidly evolving so watch this space.

Finally, if this note finds you on the beach – switch off all electronic devices immediately.  We need you rested for the autumn.  Have fun. 

Suggested citation

Dixon J (2011) ‘Summer fun and international learning on health care reform’. Nuffield Trust comment, 17 August 2011.