Archive for March, 2011

What makes practice-based commissioning difficult in practice?

Wednesday, March 30th, 2011

by Philip Boxer

The UK Government wants practice-based commissioning in order to sustain an effective focus on the increasingly chronic conditions of an aging population – in a way that can hold clinicians accountable (see the Executive Summary in Practice-based commissioning: budget guidance for 2010/11. But why has it proved so hard to make happen in practice: Practice based commissioning: what future?)? And why do doctors appear to be resisting the pace of the latest changes (UK national Health Service reforms mobilise doctors)?

What’s the problem?

“To Err is Human”, in considering how to build a safer health care system, identifies three types of error[1]: type I errors of execution in the way some particular treatment is administered; type II errors of planning in the way treatments are combined to treat a particular patient’s condition; and type III errors of intention in understanding what the particular patient’s condition really is. The first two of these are used to argue for securing the better operation of health care systems and for evidence-based approaches to defining patient pathways through them. But however well these two are managed, the quality of health care ultimately rests on the way treatments are aligned to the patient’s actual condition. Practice-based commissioning aims to improve the quality of care in general practice by enabling the responsibility for this quality to rest as close as possible to the patient within the GP consortium.

In meeting the challenge of Health Care Reform, Tom Flynn and I identified three corresponding kinds of benefit delivering step-change improvements across the UK’s NHS (a version of these relating to business is in the three agilities). These benefits came from minimising the scope for the health care system to make each type of error:

  • Type I Benefits – defining current demand for treatment and realigning care pathways to deliver them more effectively.
  • Type II Benefits – re-organising referral protocols and the configuration of clinics to improve patient pathways with respect to particular conditions within existing demand catchments defined by the Primary Care Trusts (PCTs).
  • Type III Benefits – extending the organisation of the clinical service to include re-organisation of the way patients’ demands were themselves defined by focusing on the through-life management of patients’ chronic conditions.

The orthotics pathfinders, carried out for the Purchasing and Supplies Agency of the NHS, were used successfully to test this approach in practice (for example as reported to the Scottish Parliament). They established that the scale of Type II benefits were significantly greater than Type I benefits because of the role that could be played by the orthotics clinic within the larger Primary, Acute and Long Term Care contexts. It was expected that this would be even more true for Type III benefits, but the Type III benefits could not be achieved until alignment to patients’ needs could be addressed within the larger NHS system, including collaborating with community-based services.

Practice-based commissioning was intended to deliver this alignment, with the map of medicine pathways going a long way towards defining how these Type III benefits might be achieved for patients. So why the continuing difficulty? The answer would appear to be partly structural differences between the way PCTs and GPs’ practices defined value; and partly a lack of the appropriate forms of support for sustaining the through-life focus on patients’ conditions needed by the clinicians.

Using the wrong model of value

In their 2006 book on Re-Defining Health Care speaking primarily of the US health care system, Porter and Teisberg argued the following:

“Health care is on a collision course with patient needs and economic reality. In today’s dysfunctional health care competition, players strive not to create value for patients but to capture more revenue, shift costs, and restrict services. To reform health care, we must reform the nature of competition itself.”

Central to this reform was value-based competition, something Porter enlarges on in his more recent challenge to outdated approaches to value creation and their failure to create shared value. Creating shared value means focusing on creating value in the life of the patient as well as for the provider – in terms of the above, creating Type III benefit. This argues that the continuing difficulty is because the implementation of the reforms is using the wrong model of value: managing the direct value created by providers rather than managing the indirect value created for for patients (creating value in ecosystems enlarges on the tension between these two kinds of value).

The ‘model of value’ means here the whole way in which the health care system is enabled to deliver health care, with the shift towards a primary focus on creating shared value representing a shift from a supply-side focus on markets for treatments to a demand-side focus on delivering value to individual patients.

Not supporting clinical leadership

The lessons from developing effective joint commissioning showed the importance of being able to align managed care in community and hospital settings to the through-life management of the patient’s condition within the context of their day-to-day life. This joint approach is fundamental to the practices of Kaiser Permanente, with the role of clinical leadership central to successfully transforming health care. These lessons are repeated by the early lessons in implementing practice based commissioning, showing the importance of a number of different things needing to come together: strategy, clinical engagement, managing the finances, information, and supporting practices and governance.

Current evidence on the implementation of GP consortia suggest, however, that the emphasis is still much more on migrating the top-down funding away from the PCTs to the GPs, than it is on how the GP consortia themselves need to manage health care expenditures in a different way. But in order to secure type III benefits, East-West dominance is necessary in the way GP consortia are run, in turn requiring four things:

  • Central leadership that understands the need to delegate authority to the practices where the patient’s needs are defined (i.e. asymmetric leadership), including the need for balance between these four things;
  • Practices that can focus on the through-life needs of their patients’ conditions (i.e. strategy-at-the-edge);
  • Agile health care infrastructures capable of being aligned to the particular needs of individual patients (i.e. agile infrastructures); and
  • Data platforms enabling practices to generate the multi-sided information they need if they are to be held accountable for the through-life performance of their patients’ health care (i.e. making it in GPs’ interests to be held accountable in this way).

A top-down focus enables clear progress to be made on the first two of these, while limiting the third to the forms of agility supporting Type II benefits (e.g. 18 week patient pathways). But a top-down focus prevents the fourth movement from vertical to horizontal forms of accountability (e.g. GP consortia could inherit PCT debt). This is perhaps why the GPs appear to be resisting the pace of the latest changes.

What is difficult in practice

So what might be proving difficult about practice-based commissioning in practice? The delay in giving primary focus to supporting clinical leadership probably reflects an uncertainty over whether or not it is really necessary to make the change to the axis of accountability as implied by practice-based commissioning, from top-down (vertical) to edge-driven (horizontal) accountability.

If so, it will result from the difficulty in grasping Porter’s and Teisberg’s “economic reality”: that the primary emphasis of the health care system must move from the top-down control of treatments to supporting systems of engagement with patients’ conditions that can enable GP consortia to be held accountable for creating indirect value: value in the life of their patients.

Notes
[1] These are described in greater detail in ‘Unintentional’ errors and unconscious valencies

Managing Primary Risk and the Value Deficit

Wednesday, March 16th, 2011

by Philip Boxer

The UK Government is proposing to remove the superstructure of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) and delegate authority to the General Practitioners (GPs) at the edges of the health care system.  How will GPs manage?  How will they be held accountable? And how will they balance what is collectively affordable by the nation with the good of the individual patient?  It will be some time before there will be answers to these questions, but I propose that the issues can be usefully framed in terms of how GPs manage primary risk.

Primary risk and the value deficit
The traditional use of ‘primary task‘ is in terms of the primary task of the organization. For example, the primary task of the PCT is to provide healthcare for its patients.  The funding for the PCT is determined by a formula related to the characteristics of the people within its defined territory.  The healthcare needs of its patients are determined by the GPs caring for those patients.  The primary task is realized through the way the PCT organizes and holds accountable the services it provides to its patients.

In practice, there is always a gap between the services available to treat the patient and the patient’s particular needs – what we shall call a value deficit, the value being the value to the patient of the services provided.  ‘Value’ here is the way the patient values the services provides, which may or may not be expressible in monetary terms. Value in these terms is therefore to be distinguished from the costs of the services provided.

A recent study by McKinsey’s of the costs of chronic healthcare in Germany showed over 80% of costs arose from patients with conditions that were chronic: GPs were having to manage services through the life of the patient’s condition, with the ways in which this through-life management was provided having a significant impact on the through-life costs of the patient’s condition.

The organization’s perspective on primary task therefore becomes insufficient to address the variation at its edges arising from GPs varying through-life management of their patients’ conditions.  The organization also has to find ways of managing primary risk: the risk that for any given patient’s condition, the value deficit will be unacceptably large.

The need for organizations that can support East-West dominance
Those of you familiar with the principles of asymmetric design will recognize the need for East-West dominance in the design of an organization capable of managing primary risk, since the average proscriptions of North-South dominance only hold the doctor accountable for aggregate measures of performance.  East-West dominance becomes necessary if the through-life costs of treating patients’ conditions are to be managed across such variation, as evidenced by the performance of Kaiser Permanante.

So getting rid of the SHAs and PCTs may make sense if they have been judged to be unavoidably North-South dominant.  But we still need to consider how the commissioning processes of GPs are to support East-West dominance. This was something that we began to consider in the Orthotic Pathfinder Projects, and in the platforms needed to support them.

In managing primary risk, doctors are familiar with the need to avoid errors of execution (treatment applied wrongly) and errors of planning (wrong combination of treatments) with respect to their patients’ conditions. But holding doctors accountable within East-West dominant forms of organization also means enabling them to avoid errors of intention (treating wrong condition).[1]

The systematic under-use of treatments found in the Orthotics Pathfinders was not because the doctors didn’t understand what the patients needed.  It was because the North-South dominant systems of accountability under which they worked had perverse incentives built into them that made it impossible to provide through-life treatment of their patients’ conditions, other than at personal cost to themselves.

I guess what is unacceptable at the level of the individual cannot be assumed to be addressed by adopting the same approach at the level of the government of averages. I guess the present UK government assumed this when they abolished the SHAs and PCTs, but they nevertheless appear to have replicated the same difficulty for practice-based commissioning: East-West dominant forms of governance really are different to North-South dominance forms of governance!

Notes

[1] For more on the different nature of errors of intention, see ‘Unintentional’ errors and uncosncious valencies.