Would we know it if we saw it?

Blog post

Published: 30/05/2013

A week after the Government's integrated care pioneer programme kicked off, the evaluation of North West London's integrated care pilot was published. The ingredients of the pilot were sensible, for example: investment in IT, risk stratification and targeting of high risk patients, leadership, coordination of multidisciplinary groups, and project management.

The results so far: high commitment by professionals; greater collaborative working across teams and with social services; better care planning which improved patients experience; and, for the first three months of the pilot, no impact on emergency admissions.

OK, three months is too early to make a dent in emergency admissions. Effective integrated care probably takes years to develop – a minimum of three to five years of constant (read undisrupted) effort.

In fact, of the many evaluations done by our team of 'out of hospital' interventions in the last five years, only one seems to have had a significant impact in preventing emergency admissions: palliative care provided by the Marie Curie Nursing Service.

In a cool financial climate, without much prospect of game changing levels of provider competition, and with integrated care a likely slow burn, what might bend the efficiency curve upwards fast enough?

In the face of this third sector triumph, there is perhaps some irony in the finding published last week that NHS spending on third sector providers has flat-lined for the last five years, yet NHS spending on non-NHS providers as a whole rose steadily from £5.6 billion in 2006/07 (2011/12 prices) to £8.7 billion in 2011/12.

There was no obvious upward blip with the change in Government, rather that private providers steadily picked up NHS business as their revenues from private payers fell by almost six per cent in real terms between 2008 and 2011. By 2011/12, almost 19 per cent of NHS-funded hip and knee replacements were delivered by private providers.

While Clive Maxwell, Chief Executive at the Office for Fair Trading, signals a proactive stance with respect to regulating competition in health care, events may conspire against much further expansion in use of private providers by the NHS.

The first is the list of factors preventing a 'fair playing field' as assessed recently by Monitor, in particular those acting on commissioners. Second is the extension of national tariff into more services – unattractively low for many private providers.

Third, as Matt James, Chief Executive, Private Healthcare Information Network, noted at our recent seminar on competition, with the Institute for Fiscal Studies, the supply of private care is limited: independent sector treatment centres (ISTCs) are near capacity and no more are being built; only marginal capacity remains in private providers; and new purpose-built hospitals are unlikely as investment is risky and thus difficult to obtain.

But fourth is forthcoming spending reviews. On 26 June the protected ring-fence around the NHS budget will most likely remain but become less protective. In the spending review after the next election in 2015, expect more fundamental change for reasons spelt out in our report last December: A decade of austerity? The funding pressures facing the NHS from 2010/11 to 2021/22.

In a cool financial climate, without much prospect of game changing levels of provider competition, and with integrated care a likely slow burn, what might bend the efficiency curve upwards fast enough?

I'd like to hear the presentations on this question from applicants for the top job at NHS England. The answers though may be somewhat boring.

Consistent intelligence, hard graft and collaboration on a number of fronts to: unblock reconfigurations; progress reform of payment currencies and prices; boost the out-of-hospital offer including remodelled primary care; improve data on service use and costs for starters.

But perhaps a better question for David Nicholson hopefuls is: could we recognise a bent efficiency curve if we saw it? More on that later.

Suggested citation

Dixon J (2013) ‘Would we know it if we saw it?’. Nuffield Trust comment, 30 May 2013. https://www.nuffieldtrust.org.uk/news-item/would-we-know-it-if-we-saw-it