Getting healthy, not just getting better

Gemma Self writes about how health care is funded – and how a future of health service providers being paid to keep people well might look. Gemma is
Director at
Reimagine Health, a small consultancy focused on redesigning incentives in
healthcare to focus on patient outcomes and prevention across the UK. She is an alumna of the NHS Graduate
Management Training Scheme and has held a variety of leadership and
implementation roles within healthcare. This is part of a series of blogs, where key players in Bristol’s health sector write about a health related subject of their choice. If you want to contribute, email
[email protected].

How changing what we pay for can
radically improve healthcare in Bristol

Imagine a healthcare
system in Bristol that is designed to keep us healthy, and is paid to achieve that.

How organisations delivering healthcare are currently paid
is a complex picture and many of us don’t think about paying for our
healthcare; generationally there are few people left who have had this
experience in the UK.

How we as a society measure health and invest in keeping
people healthy, however, can have a significant impact on the services we
receive.

Currently, every time we use a service delivered by the NHS,
that organisation is paid on our behalf. Some are paid upfront to see a
predicted number of people. Some are pay-as-you-go, for every day someone is in
hospital and for the specific type of test or procedure they have done. Pay-as-you-go
payment is quite sophisticated and has led to a significant reduction in
waiting times in hospitals.

If a hospital is paid for every procedure and night in a
hospital bed, from an economic perspective it is in their interest to keep
people rolling through their doors. (It is of course, not so simple, as
hospitals already have financial incentives to not keep people in hospital and
healthcare’s sole purpose is to ensure people get better.)

Currently, our health
system isn’t paying for what people really need – to be healthy, physically and
emotionally, and ideally, not get ill in the first place. So we are in a state
where we need to find a way of paying for what we, our families and friends
need.

We are moving towards a future where there are bundled
payments for health – where providers are paid on an annual basis to deliver
any services needed to keep people healthy. They could then get a bonus reward
when there is evidence that this has been achieved. This means that the
provider delivering the service is required to think about working with other
organisations to prevent ill health, or else they have to fund the impact.

You may be the son, daughter, grandchild or other relation
of an older person with a number of health conditions and who is living alone. They
will probably visit their GP and hospital services over 10 times per year, sometime
requiring an ambulance. They may go to a group run by a local voluntary sector
provider to help them to meet others in the area.

Currently the local system pays separately for each of those
services and interactions. So there is no financial incentive for any of the
providers of those services to work together or prevent any future episodes of
ill health. They treat an issue as it arises but then see the end of that
episode as a success. Yet, most healthcare professionals can predict the future
healthcare needs for that individual.

Imagine what a future
could look like if organisations were paid to ensure that older people spent
more time at home, felt in control of their health, had an agreed individualised
care plan and their blood pressure was reduced.

In this scenario, the hospital needs to think about working
with the GP and the community health team to proactively support the patient to
know what to do about all their medication. Perhaps the lead organisation now
responsible for older people’s care buys in some transport to ensure that
patients who struggle to get to their appointments are taken there. If more
than an anticipated number of older people go into hospital due to a need that
was preventable, the organisation responsible could have to absorb the cost,
recognising that their service wasn’t working. Innovations and investments to
prevent ill health would rapidly ensue.

This whole concept is Value Based Healthcare. With the
principle that instead of planning for and delivering hospitals based on volume
(number of patients and how long they wait), a whole system moves to measuring
health on the basis of whether patients are healthy and happy.

It’s a future state
that focuses on getting people with long term health conditions to stay as healthy
as possible, for older people to spend more time at home and for people with
serious mental illnesses to be able to work.

There are very few alternatives that provide such a rosy
picture for how healthcare could be delivered in the future. With a growing
momentum for this approach both in the UK and around
the world, Bristol is also thinking about how different organisations can come
together to focus on these goals.

With the city’s
ethos towards locally produced innovation, social improvement and a strong moral
standing, we are in the perfect climate for creating a bright future for
health.