Who is responsible for diabetes outcomes in your place?
The core of the Triple Aim is to improve population health. Clinical outcomes, for people with long term conditions, is benchmarked as a measure of success. This is enshrined in the NHS 10 year plan and the expected legislative reforms aim to put the structures in place to achieve it.
Medicine is inherently uncertain, it requires co-ordination with teams of professionals and things go wrong. The way we manage this is a sign of our maturity, individually and organisationally. Another aspect of the Triple Aim- patient experience.
The third part of the Triple Aim is affordability, the optimal use of financial resources to improve care and experience. We know that prevention is better than cure and represents a good use of financial resources over time.
So it would seem to be a perfectly reasonable question to ask, who is in charge of these outcomes, experience and costs for a defined long term condition in a place?
The 10 year plan, with it’s PCNs, place based integrated care partnerships and overarching integrated care systems, is a welcome evolution of what we have been defining operationally for at least 15 years, probably longer. Torbay Integrated Care Team was formed in 2004 (ref 1). It is a transformation in which organisations are being expected to merge their functions.
There is plenty of experience of mergers in the public and private sector. Beyond the right people and the right process, one unavoidable fact is that merging is only successful if it aims to do different things, not just to do things differently.
One further lens for this consideration, is to define the terms responsibility, authority and accountability.
Authority: The power or right to give orders, make decisions, guide the actions of others and enforce obedience.
Responsibility: The obligation to achieve delegated objectives.
Accountability: The obligation to report and be answerable to the authority for the discharge of those responsibilities.
If we wish to integrate our service around a person’s need or population need, it is easy to see how our current health and social care public service is not fit for purpose. There are two authorities, the tiers of government and the NHS. Patients themselves of course have authority, but in the public services (as opposed to a consumer model) they have delegated these to the state.
As clinicians we are accountable to our patients and have professional responsibilities, but have no control of the deployment of the resources to satisfy our obligations. Chief Execs of NHS bodies are accountable for their institution’s responsibilities which perpetuates the competitive silo working of our fragmented system. CCGs theoretically have authority over local NHS services, but have mostly been unable to control the spend of their Acute Trusts who are more fearful of the power of the regulators, whilst risk averse clinical practice is out of control and driving up costs.
Returning to our question, who is responsible for diabetes outcomes in your place?
By now you may have formed an answer, but I suspect not.
Diabetes is common and easy to understand the significant role of prevention to improved population outcomes, so let’s uses it in this consideration. There are a number of suspects that could take charge.
Is it a clinical responsibility?
The PCN clinical director as a GP would be a reasonable choice. To exercise the responsibility he or she would expect some control of the resources, which includes the specialist service as a subordinate. We have tried this before. GP fundholding was an attempt at this, but proved politically unpalatable. It was replaced by practice based commission which became a talking shop with no power to control resources. Attempts in the 2012 reforms to create accountable GP Consortia at 50,000 population level, proved unmanageable for the top down control of the NHS Commissioning Board.
The local diabetes specialist could also fulfil the responsibility. As a GP it strikes me as strange that the GP who knows the least about a condition is the one who decides who should see the specialist. In “Teams without Walls” we described the specialist role back in 2012 but specialists have shied away from population based responsibilities and community working. It would be perfectly possible to have a spreadsheet of all the diabetics in the population with all their metrics and spot where things are going wrong to intervene proactively. My GP colleagues would have to accept subordination to the specialist who would expect control of the resources.
Is it a an elected member of a Local Authority?
The medical model, however, focuses clinicians on those people who have a diagnosis. We are looking for a responsibility that covers primary prevention as a key driver of population outcomes. That power could be delegated to the lead clinician through legislation.
I was elected onto a Local Authority some years ago and was surprised to learn the extent of the statutory duties of local authorities towards health and wellbeing. This is why they provide leisure services, open spaces, social care, planning controls etc. Local Authorities are democratically accountable to their defined populations, the people can remove them if they fail in their duties. Most European countries who have publicly funded health care systems organise them though their versions of our higher tier Local Government, Municipalities.
Health and Wellbeing Boards were established in the 2012 reforms precisely to bridge the NHS/Local Authority gap. I suspect most of us are only vaguely aware of them and could not name any of the members. But the chairman of the Health and Wellbeing Board, as an elected representative would be a strong contender, if we found a way of giving them strong authority over the full health and care system, budget responsibility and local pay bargaining powers with the NHS as a subordinate. They would only be commissioners though, and our experience tells us if we are aiming at service reform to improve population outcomes, then it is the providers who are the most able to do this.
Is it the Chairman of the Hospital/ICP?
In Alzira, Spain, a municipality under extreme public financial pressure, with a large failing hospital, replaced its public management with a private company and gave them a population based outcomes incentivised contract. They now have the highest performing outcome figures in the country at the same time as being the most efficient and yielding a profit for the private company on less budget than the previous public management. To achieve this they have taken over the local GP service and used the lever of pay to encourage specialists to work more closely with GPs to reduce the volumes of patients coming through the hospital. (ref 2)
This is a very potent model and well known to policy makers who do not struggle with the independent contractor status of GPs and have tried for a long time to bring in an element of performance related pay.
For “Hospital” we could read “Integrated Care Partnership (ICP)”. The reality is that in most places it will be the hospital that is the dominant player. I welcome the ICP Model as its provider led and I believe that many colleagues in General Practice would consider relieving themselves of the financial risks of their property and employer status as independent contractors.
We could go one step further and let the people choose the Chairman through a democratic process. Police service reforms have done this with their elected Police and Crime Commissioners (ref 3). Bringing democratic accountability into the NHS has been a political debate for some time, we should expect to see this during the forthcoming legislative process and probably have a professional responsibility to join in.
Directors of Public Health, certainly straggle the NHS/Local Authority boundary and are respected by their clinical colleagues. They are generally very able communicators and leaders who are skilled in working with data …..and committees!
Outsourcing the responsibility to a private provider is probably too unpalatable politically, but it worked in Alzira (ref 2) and also at Kinzingtal, Hamburg. (ref 4)
In reading this far I guess that you are one of those people who take an active interest in the health and care system around you. You may even be someone who is prepared to devote some of your professional time trying to improve it. If you are, I hope that this question and narrative has given you some insights and tools to help.
Those places around the world that have solved the riddle are the ones who do not look to the rules as an excuse not to do anything and recognise that it’s people, relationships and behaviours that make this all happen. In their innovative spirit they celebrate their failures as the way to their answer.
2021 will bring the actions behind the NHS 10 year plan. Many of us will be involved in our local system’s responses. Remember the merging message that success is dependent upon doing different things. Take a chance and ask this question “ Who is responsible for diabetes outcomes in this place?” and see what happens.