A Coalition with no idea of the problem, and no idea of the solution

Health-care delivery in public and private health-care systems is demonstrably inefficient. Inefficiency manifests itself in the failure to deliver cost-effective care to patients who would benefit, poor control of patient safety which exposes patients to avoidable risks, and large variations in clinical practice. The result of these failings are that similar patients with similar needs receive variable care and are exposed to avoidable morbidity and mortality.

Rather than confronting these issues directly, reformers throughout the world are looking to the commissioners of health care, be they private insurers or public bodies such as the failed Primary Care Trusts or the evolving GP consortia being introduced by the Coalition government.

The hope is that they will use aggressive contracting to ensure improved consumer protection for patients and better value for money for payers.

Commissioning involves the efficient delivery of health and social care to patients in need. Efficiency is an input-outcome relationship — i.e. we require the delivery of those services that are not merely effective in terms of proven ability to improve patients’ health but also the least expensive.

But what is ‘need’? The patients presenting for care believes they need assistance but the supplier of health care may or may not be able to help. Thus there is often a difference between what the patients wants and what can be provided efficiently. Not all need can be met so all health-care systems ration benefits.

In a private system the rationing is related to you or your employer’s ability to pay for insurance premia and the limits of the benefit package that is offered by the insurer. In public health-care systems, rationing is ideally related to the patient’s ability to benefit per unit of cost — so care is targeted at those patients who get greatest benefit at least cost. This type of rationing is epitomised by the work of the National Institute for Clinical Excellence (NICE).

Thus rationing is ubiquitous in public and private health-care systems, although the rationing mechanisms vary. Rationing involves depriving patients of care from which they could benefit and which they would like to have.

Commissioning is thus about rationing access to care. After assessment of local need or capacity to benefit from health care, decisions have to be made about how to allocate the finite resources amongst competing patients. Crucial to this process is robust evidence of the clinical and cost effectiveness of competing health investments. This is generally limited, with less than forty per cent of common health-care interventions having an evidence base derived from well-designed clinical trials.

Sadly, all too often even these proven therapies are not delivered to patients who are members of public and private health-care systems.

The principles of commissioning are thus well understood: allocate your limited budget according to the cost-effectiveness evidence base and in relation to the patient’s capacity to gain from health-care investment.

Why do public and private agencies find it so difficult to translate these principles into practice?  

An important obstacle to efficient commissioning is that one provider’s gain is another provider’s loss. No reformer in their right mind would invent or tolerate a health care system in which primary care, secondary care and social care are insulated from each other and incentivised to defend their ‘empires’. Most health-care systems retain this fragmentation because policy makers are unwilling to risk the ruthless pursuit of what is best for the patient and the payers, public and private.

What the patients want are integrated, efficient and timely pathways of care so that heart disease, cancer, renal disease, diabetes, muscular and respiratory conditions are managed across institutions. In such a world, evidence-based pathways would retain much of the care in the community provide by general practitioners, nurses and their teams. They would be incentivised to contain treatment efficiently in the community and only refer on to hospital when appropriate.

Instead of this nirvana, care in most systems is fragmented with patients delayed in transition across care boundaries and consequently subject to frustration and avoidable morbidity and mortality.

The Coalition plans to give NHS funds to general practitioner consortia. Will this lead to vertical integration of the health-care industry, with either GPs taking over Foundation Trusts or Foundation Trusts merging with GP consortia?

Merely to suggest this highlights the obstacles to change. Reform always redistributes income and employment. Unions and professional associations would leap to the defence of their vested interests, and ‘shroud wave’ about how change may endanger ‘patients’ interests’.

‘Crablike’ policy makers proceed with reforms which all too often fail to define ‘the problem’ and explain how their favoured ‘solution’ will resolve it. The Coalition risks translating GP consortia into a new form of weak PCT-like commissioners. The white paper and the associated consultation papers appear to lack the means to improve commissioning to produce efficient and humane systems of integrated care.

The search will go on for better ways of protecting patients and payers. Any such reforms should be evidence-based and the products of careful piloting and evaluation, rather than faith.

Alan Maynard is Professor of Health Economics at the University of York.