Michael Porter and Thomas Lee have published an article in the October 2013 edition of the Harvard Business review, entitled ‘The Strategy that will Fix Health Care’. You can find it here. Or alternatively you can read this relatively short post and I will tell you what it says!
It starts with the premise that there needs to be a ‘transformation to value-based health care’. This is essentially a shift in the focus of health care delivery from value and profitability of services provided to the patient outcomes that are achieved. This transformation, it claims, is on its way,
‘There is no longer any doubt about how to increase the value of health care. The question is, which organisations will lead the way and how quickly can others follow.’
Some in the NHS understand this. The development of the Outcomes Framework is a good example of a simplistic attempt to shift the system with one golden bullet. Many, however, do not, hence the reason the Outcomes Framework has been largely ignored despite its stated importance. What is clear is that achieving this shift is far easier to say than to do in practice.
So how will this be achieved? Step one, according to Porter and Lee is to define a proper goal for the health care system. To improve outcomes for patients. Not increase volumes or improve margins, just to improve outcomes for patients. We say we have set this goal in the NHS but of course we have not. We understand it is breaking even, achieving the 4 hour and 18 week targets, and becoming Foundation Trusts that is really important.
The strategic agenda for moving to a high value health care delivery system has 6 components, which are interdependent and mutually enforcing.
The first is to organise into what the authors describe as Integrated Practice Units. These units are responsible for the full care pathway of a patient’s condition, not just the individual pieces of it. These are clinicians and managers working together to provide every aspect of care for a given disease, such as diabetes.
The second is to measure outcomes and costs for every patient. The outcomes must be those that actually matter to the patient, and be by condition such as diabetes, not by specialty such as podiatry or intervention (eye examination).
The third is to move to bundled payments for care cycles. Specifically this is neither global capitation not fee for service (the mechanisms generally used in the NHS) as neither reward improvements in outcomes for patients. This would mean a full care cycle for an acute condition; a year of care for a long term condition; or primary and preventive care for a specific population e.g. children.
The fourth is to integrate care delivery systems. I like the authors’ description of integrated care, as it has a substance commonly lacking in NHS expositions of the topic. They comment that most multi-site organisations are not true integrated delivery systems but loose confederations of largely stand-alone services that often duplicate each other. True integration, they say requires 4 choices:
I. Define the scope of the services, i.e. only deliver those services where you can genuinely deliver high value for patients
II. Concentrate volume in fewer locations, because volumes matter for outcomes
III. Choose the right location for each service line, i.e. deliver the routine and less complex out of hospital
IV. Integrate care for patients across locations. The integrated practice units should operate across locations if necessary.
Even the authors note that the politics of this is daunting, as many of us in the NHS have already discovered!
The fifth is to expand geographic reach. The time has come to end the delivery of health care as a local model only, and allow superior providers for particular conditions to be able to serve a wider population. This would either be a hub and spoke model, where a provider creates satellite facilities for the relevant integrated practice unit and fully employs, trains and rotates staff through the parent organisation. The alternative is a clinical affiliation where the integrated practice unit provider partners with community or local providers and uses their facilities and staff, but applies its own successful approach.
The sixth and final component is to build an enabling IT platform (these keep getting easier…). This IT platform would be centred on patients, use common data definitions, make medical records accessible to all, have templates and systems for each condition, and information would be easy to extract. Simples.
There is a lot in the article and I am sure I have not done it justice, so I would encourage you to read it for yourself. While much of what is suggested is both complex and daunting, there is nothing that I would obviously disagree with. Equally there is very little that could be easily done tomorrow.
As leaders in and of the NHS the starting point has to be an acceptance of the basic premise of the article, that the focus of health care delivery must become solely about improving outcomes for patients. We need to be less protective of the NHS that we have today, and engage our patients, our public and our staff in a conversation about the need for change so that we can serve them better, and so that some of the changes suggested can move from the theoretical and aspirational, to being realistic and implementable.