interviews

‘Outcome-based commissioning for specific diseases will worsen the problem’

Sir John Oldham, the former national clinical lead for quality and productivity at the Department of Health in England, now chair of the strategic advisory board for Integrating Care, has a stark warning for CCGs on their commissioning practices.

Speaking at the ISQua Conference in Edinburgh on Monday 14 October, Sir John Oldham warned that disease-based approaches to commissioning will not make a dent in the looming funding gap facing the NHS – £40bn by 2020 according to some estimates. Instead, they will make the problem worse.

NHE spoke to Sir John (pictured above) in his capacity as chair of Integrating Care’s strategic advisory board after his speech.

He told us: “By and large, CCGs ‘get the issue’ – they know it’s people with long-term conditions. But when thinking about how to commission for that, that’s when they’re coming unstuck.

“There is what you might call an emerging bubble, a race for outcome-based commissioning, but being translated into outcome-based commissioning for specific diseases — which will worsen the problem.”

Instead, Sir John wants services commissioned based on a ‘whole-person’ model of care. 

“Even the concept of a pathway is too linear a visual image of what the reality is for these patients,” he told us. “They are in a web, a network of interactions, many of which don’t communicate with each other. If you create, say, a COPD pathway, only 19% of patients with COPD have just COPD. You’re creating an outcome-based commissioning model for something that will only apply to 19% of those people. That doesn’t seem a sensible arrangement – but it’s worse than that, as you’re then locking those contracts in for two or three years. You’re going to make the issue worse.

“This is the biggest issue facing health and social care – and pursuing these single disease pathway outcomes is actually undermining the NHS.”

Asked about the barriers standing in the way of his vision for better commissioning, he said: “It’s nothing to do with resources; in fact, it’s just people thinking about working in a different way. If you pursue the line people are going down now, an outcome-based commissioning pathway for diabetes, another one for COPD and another one for heart failure, you’ll end up with what we’ve got now – which I describe as a Monty Python-esque queue of case managers outside a person’s house, dealing with just one ‘part’ of them, when it’s the whole of them that needs to be dealt with.”

He said there is a huge emerging funding gap in the NHS, and that “creating multiple teams dealing with the same person is not the way to start to reduce that gap”.

“But we know that if you have an integrated care team looking after the sets of people who are at risk, the top 10% of people say, between mental health, social care, community services and primary care, pulling in the specialist care as and when necessary – that’s when you get reduced admissions, reduced length of stay, and improved functional outcome. That’s what people should be commissioning for.”

He said it should be a partnership between providers and commissioners and suggested there was a ‘Dunkirk moment’ in many health economies, but that instead of joining together to deal with their shared issue – people with multiple complex conditions – organisations have a segmented response.

But in some areas, there are genuine partnerships, he said. He praised an initiative in Manchester involving key providers, the council and CCGs aimed at facilitating early discharge and to drive service changes across the city region.

He added: “In Leeds, there’s a similar high-level strategic board being driven across the whole city by the CCGs and the providers to change what’s happening.

“Instead of talking about pooling budgets, we need to accept that for this group of people – who account for 70% of activity in the health and care system – the current tariffs on payment-by-results are inappropriate. It’s incentivising the wrong behaviour.

“Instead, we need to move towards what I was creating before I left the DH, which is a year of care capitation tariff for a section of the population, where the outcomes you want from commissioning that year of care have to be owned and delivered by all the providers collectively. You then start to move into a different territory.

“We have a system largely built to respond to what was needed when the NHS was first founded in 1948; infectious diseases, for example.

“We now have a whole set of different issues. Collectively – as managers, clinicians, royal colleges, whoever – we need to grasp the fact that complex need is the frontier of healthcare in the 21st century.”

Asked whether his warning applied to CCGs or to NHS England too, Sir John told us: “The devolved system now is such that those decisions are owned by the CCGs.

“What I would say to NHS England is that it’s completely irrational to have 18 ‘national clinical directors of body parts’, when the biggest drivers in the system are not in that territory.”

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