Changing the NHS – Preventing Ill Health – 4

In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).

Developing Alternative Financial Incentives

While financial incentives are not the only way in which secondary prevention can be spread throughout healthcare the current fragmented method of distributing NHS finances in fact gets in the way of funding prevention that actually prevents.

What is needed is a set of moral arguments for doing the right thing (the public facing narrative) coupled with a financial system that helps that along rather than getting in the way.

Cutting to the chase here. In the next decade one of the aims of NHS secondary prevention must be to reduce the amount of resource being spent when the exacerbations of long-term conditions cause people to spend more time in hospital emergency beds. Over the coming decade there will not only be a rise in the number of elderly people with long-term conditions but also the length of time they have them. If we continue to treat them in the same way as we have patients with similar acuity in the past, it is difficult to see how the NHS can survive.

Indulge me. Stop and read that last sentence again. If we believe that our generation has a stewardship responsibility for the NHS – and therefore a responsibility to hand it on to the next generation in a decent condition, that sentence really matters.

If, over the next decade, we don’t begin, year on year, to reduce the number of days spent by people with long-term conditions in emergency beds, we will have failed in maintaining that good stewardship and will consequently fail future generations.

My very strong suggestion therefore is that we make sure that we develop NHS financial flows which encourage successful secondary prevention as a mainstream NHS activity.

If we get a lot of things wrong – it will be very bad for many people. If we get financial flows wrong, the NHS will not survive.

It is therefore one of the core issues that, when we talk about an ‘NHS Model of Care’, needs to change during the coming decade.

The key point here is not about any old form of secondary prevention, but specifically the prevention of patients spending so much time in emergency hospital beds.

And I am NOT saying that this is the ONLY aim of NHS secondary prevention for people with long-term conditions. There are millions in the population that will have much better lives if the NHS succeeds in better preventing their conditions from worsening.

I agree that we should make sure that secondary prevention thrives for a wide range of long-term conditions. But more significantly, if we don’t succeed in the specific prevention of people with the same acuity going into the same emergency beds as they have done over the last ten years the whole NHS model of care is at risk.

There are a number of other necessary financial reforms that will make this work. Firstly – something I have been going on about for quite a few posts – we need one part of the system to pay acute trusts to carry out more elective work. To repeat the mantra – normal in the rest of our society – we need a system which will pay elective trusts more money for doing more work. (Readers of my recent post will note that we have a system at the moment which pretends to do that. But what it actually does is pay some trusts for more activity and then pay similar amounts to trusts who don’t. To be entirely clear. This is NOT what we mean). If hospitals are paid more for delivering more elective care, they have an incentive to have emergency beds clear to carry out it out.

Second, if a trust is paid more for doing more elective work, then they need to be able to keep it at the end of the year. To restate the obvious point about incentives, if money made from doing extra work is clawed back because NHSE need to balance someone else’s books, then the incentive to continue doing it disappears. Working harder to earn more money for doing more work is an incentive. Knowing that money will be taken away from you at the end of the year, isn’t.

But the main financial flow we are exploiting here would be payment for successful secondary prevention in domiciliary primary or community care. Again to make the point. You do not get paid for this prevention work if it doesn’t prevent. The point of calling this work prevention is – yes, you’ve guessed – that it will successfully prevent. And in this case, it would be aimed at preventing people who last year had spells in emergency beds, from having those spells this year.

On its own prevention may be a very good service. Let’s call it good primary care – but unless it prevents, we really shouldn’t call it preventative.

And the point about the financial flow is that if some emergency beds are no longer occupied by patients who previously filled them those beds can be used for elective work to earn extra money.

The challenge lies in managing the mechanics of this new flow.

Since the expenditure of resources on secondary prevention that leads to emergency beds being freed is spent in either domiciliary primary or community care, some of those resources need to flow to the place where the initial investment takes place.

I am making the case for a very specific new financial flow around this example of secondary prevention to make a wider point about new financial flows.

Unless the NHS (and social care) reorganises its finances in such a way as to financially reward where the necessary investment in secondary prevention takes place, such prevention will remain a hobby, rather than a mainstream part of the NHS service.

To move it into the mainstream, to make it big enough to play a role in changing the current NHS model of care, will need new financial flows that reward success, rather than pay for failure.