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Is care for people with rheumatoid disease better in Liverpool or Manchester?\nIs care for frail elderly people better in Somerset or Devon?
\nWhich big city has the best service for people with bipolar disorder?<\/p>\n
Is care for people with rheumatoid disease better in Liverpool or Manchester?
\nIs care for frail elderly people better in Somerset or Devon?
\nWhich big city has the best service for people with bipolar disorder?<\/p>\n
After\u00a060 years of the NHS and\u00a020 structural reorganisations these questions, and similar questions about other health problems, still cannot be answered. Neither can they be answered in any large “developed” country, but they could be answered in England soonest because the NHS in England is the only large country with programme budgeting. We know, for example, that we spent \u00a392m per million population on musculoskeletal disease, \u00a3117\u00a0m per million population on cancer, and \u00a3 25m per million population on mental health services in 2009\/10. Furthermore we know this by population, and by primary care trust at present. We\u00a0could therefore measure the relationship between outcome and resources and the value of services for different populations, but not if we continue to focus on “providers” and “commissioners,” or “primary” and “secondary” care, or “hospital” and “community” services. These are 20th century terms, based on 19th century bureaucracies, describing aggregations of parts of systems, and it is competition between hospitals or insurance schemes that forms the basis of the recent literature on competition. (1,2,3,4, 5) It is systems that are needed, systems that compete with one another on the value they provide\u00a0for patients in the population that they serve with the only incentive or reward being professional pride in a job well done.\u00a0<\/p>\n
Although the development of hospital and primary care services has been a great achievement in the last\u00a050 years, they are only one dimension of care. The other is the patient\u2019s problem \u2013 pelvic pain, or breathlessness, or rheumatoid arthritis:\u00a0 these are the eternal verities of healthcare whereas “commissioners,” or “foundation trusts,” or “health maintenance\u00a0organisations”\u00a0are ephemera. The need for the second dimension that focuses on health problems was argued many years\u00a0ago, also in a time of “zero growth” (6) and there has been progress in some conditions such as cancer, but it has usually been where technology has forced some change, with people from different institutions needing to work in networks to create systems. Most healthcare in most countries resembles Brownian motion, the random movement of patients, professionals, blood samples, and documents. What is needed are systems.<\/p>\n
A system is a set of activities with a common aim, for example \u201cto minimise handicap in young people with severe disabilities.\u201d\u00a0 The aim is amplified in a set of objectives which define the scope of the system, for example defining whether or not\u00a0a system for people with chronic obstructive pulmonary disease includes responsibilities for prevention and terminal care.\u00a0 A set of objectives for an epilepsy system, prepared at a workshop, are set out below:<\/p>\n
For each objective one or more criteria are identified, both process and outcome. The outcomes need to include both benefits and harms, because one aim of the system is to achieve the optimum balance of good and harm from the resources allocated. For this reason too, standards may include upper rates of testing or referral as well as lower rates to minimise overdiagnosis and overtreatment, as well as minimising underdiagnosis and undertreatment. Systems are delivered by networks. A\u00a0network is a set of individuals from different bureaucracies who work together, and trust one another, and although there will be contractual relationships between the bureaucracies the key element is trust. The systems are expressed as pathways and localised care maps using internet based tools like the Map of Medicine make the usual pathway of care clear to all patients and professionals.<\/p>\n
Competition by systems for better value Competitive screening systems Ten years, twice as long as the Second World War, to translate efficacy to effectiveness, was this period too long, or was progress too slow?\u00a0 Perhaps, but population based systems, each accountable to the population served through an annual report, and competing for pride achieved this. Cancer, cardiovascular, and end stage renal failure services have also developed this approach, but we need to do it for all health problems and patient groups.<\/p>\n Accountability to and engagement of the population served Only systems competition does more good than harm King Kong, Godzilla, or the ants?<\/strong>The King\u2019s Fund report on competition recognised the complexity and the potential of combining integration and competition, and calling on the NHS Commissioning Board and Monitor, the big beasts, the King Kong and the\u00a0Godzilla of healthcare, to bring this about, (10) but maybe this is just too complex for big bureaucracies to manage. Perhaps it is better to leave it to professionals and patients to create the\u00a0 systems and the networks cooperatively, just like the ants do<\/a>.<\/p>\n
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\nCompetition, like all medical care, can do harm as well as good. Competition between “providers” on hospital criteria such as compliance with standards, appears to do more good than harm, though quality improvement too can have unintended consequences. What is needed are population based systems competing on value, on outcome, and cost. The issue of cost cannot be avoided because if resources are used and produce low, or no, value it is not the tax payer who pays but those other patients whose needs could have been met with that wasted resource, and there is evidence that this type of competition works.<\/p>\n
\n<\/strong>Screening is relatively, but only relatively, simple to run as a system, particularly if there is a green field site on which to design and build the system, as was the case with screening for breast cancer.\u00a0 All screening programmes, like all medical care, do harm as well as good. The balance of good to harm demonstrated in the research on which the policy decision to introduce breast cancer screening is based,\u00a0is best described as the efficacy of the service, when its results were performed by highly experienced experts working to protocol. To minimise harm and maximise benefit the English Breast Cancer Screening Programme developed a set of objectives and used identical criteria to measure progress, or the lack of it, and produced an annual report of how all the systems, or programmes as they were called, performed in comparison with national standards and with one another.\u00a0 It took five years for the mean performance of the English programmes, about one hundred in number, to achieve the Standardised Detection Ratio (SDR) set by the research\u00a0teams. That is for the effectiveness to match the efficacy to use more formal terms. It was recognised that the performance of the research terms would also have improved in that period, but the competitive system was designed to maximise benefit and minimise harm in all the programmes. Standards relating to the process of screening were set, with every programme competing to achieve a position in the top quartile and with those in the top quartile aspiring to be the best, expecting no reward other than their sense of achievement and pride. Minimal acceptable standards below which no programme should fall were also set, but programmes which were below this standard received neither humiliation nor additional resources, but help from other programmes to improve. After\u00a010 years the worst performing programmes were also achieving the SDR of the Swedish research teams (7).<\/p>\n![\"figure\"](\"http:\/\/www.bmj.com\/site\/blog\/icons\/muir_fig.jpg\")
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\nThe population size varies. For a common condition without the need for highly specialised interventions, asthma or the problems of frail elderly people for example, a population of\u00a0300 000\u00a0would\u00a0 generate enough activity for meaningful comparison.\u00a0 For other conditions a larger population base would be appropriate to measure variations in less frequent interventions, for example a population of two million for epilepsy, while there might be a need for only three or four systems in England for childhood metabolic diseases. The professionals responsible for these systems would naturally compete with one another on quality, outcome, and the use of resources.\u00a0 So too would the patients and carers who are partners in the system. Their feedback offers opportunities to improve quality and safety, their suggestions offer opportunity for redesign, and they would want their service to be the best:\u00a0 co-ownership is effective. The annual reports from the systems, perhaps\u00a0100 for asthma and\u00a030 for epilepsy could be compiled by the relevant national charity, so that the system would be accountable to the population served, both nationally and locally.<\/p>\n
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\nThus it is not possible to generalise about competition.\u00a0Some competition is ineffective, some does more harm than good, but competition between systems accountable to defined populations is effective.\u00a0 The luminaries of the business world (8,9) have now joined the call for this approach and there is evidence to support it.\u00a0 The core business of healthcare is not its institutions, which are necessary but not sufficient, but the problems borne by patients and carers. These should be the primary focus of a health service which should encourage competition to maximise value.<\/p>\n