A time of great opportunity in English healthcare

28 September 2016

This is a time of great opportunity in English healthcare. There is wide agreement on the need to move from what can feel like a fragmented service towards seamless provision across a whole patient pathway. The vision of a united service that works together to achieve better outcomes is a powerful one that will command strong public support.

In particular a new approach could unlock considerable value for money from within the service. Commissioning tends not to focus on value for money other than in a crude sense of overall comparative costs based on tariff or outcome of procurement. Commissioning also tends to measure just one episode of care in one part of the pathway, rather than the whole. As a result commissioners have an unenviable job of trying to piece together the offerings from multiple providers across various care sectors to make sense of what could be improved and where better investment would lead to better outcomes.

This is compounded by providers giving too much attention to the individual component of the service that their organisation provides rather than the wider interest of the patient or populations being served. Further, there are limited incentives for providers to deliver value for money if the recipient of the value gain lies further up or down the pathway. This is the concept of the ‘fruit of the tree falling in someone else’s garden’.

The better alternative may be to see the delivery of care along a pathway as a supply chain. In this model, a lead provider would be commissioned to provide ‘total pathway care’. If different providers contributed to that pathway of care, they would share in the value which the pathway creates. Lead providers would compete rather than hold monopoly positions.

At that point, NHS England and others can move decisively towards payment by outcomes, with all of the benefits that would entail. For truly integrated care, primary care should join the group of total pathway providers.

In my review of NHS provision for the Department of Health, I concluded that England has been slow, compared to other countries, in exploring new patterns of provision such as hospital chains and management contracts. There is now a welcome spirit of change across the Service which will, in turn, develop the better services that patients want and deserve.

Sir David Dalton, Chief Executive, Salford Royal NHS Foundation Trust



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