UPDATE COMMENT
I
remember the day they stopped booing me at NHS conferences. It was on 15 July 2009 in York and I was speaking to around 100 associate director-level PCT commissioners about how they might improve their negotiating performance with their local providers. It used to happen a lot. On a good day it was only hissing.
When something like this stops, you begin to wonder why the audience reaction is different. Is it you or is it them – but then the content of my presentation hadn’t really changed much over the previous two or three years. What I talked about was my experiences with health commissioners on both sides of the Atlantic and how much better the US was at using its data to manage the care purchasing process. I always knew that NHS traditionalists in the audiences found some of the words I used hard to swallow. These included ‘private sector’, ‘US’ and ‘health insurance’ or various combinations of them. It got a lot of NHS traditionalists, shall we say, exercised, which was when the booing would start. The opinions I held had been fashioned by over 15 years of experience negotiating with tough hospital managers in the US and in the private sector in the UK. These were people who were highly schooled in the business of achieving commercial advantage for their organisation and didn’t miss many tricks. They used data wherever they needed to win an argument. And there was lots of it, immaculately crafted to support every single point.
PROFESSIONALISATION OF COMMISSIONING What I began to notice about PCTs in 2009 was that commissioning was professionalising, thanks mainly to the adoption of the learning that came from the often-maligned World Class Commissioning programme. Many PCTs had begun to accept that they should take a firmer line with the management of hospital trusts, particularly the large acute foundation trusts. And I was never booed again. Now, more than three years on,
I suddenly feel vindicated by no less than The Lancet in a paper it published in October under the title ‘Healthcare Reforms in the USA and England: Areas for Useful Learning’. Part of what the authors have to say is that healthcare systems, wherever they are, ‘need to take information from electronic records, and share, link and analyse it to support improved clinical and patient decision- making’. Where the US has always been stronger, ‘is in the development of complex algorithms to prospectively model expenditures’ and that ‘the NHS could learn from the transparent and analytic rigour [applied] in the US’. During the booing years, I never once advocated that the US healthcare system should be brought here, God forbid, but I certainly knew we had a lot to learn from the US approach to analytics and the way the knowledge could be applied to improve commissioning systems.
That there is now an NHS market is no longer disputed, even by the diehards. We’ve all moved on. But as a market, it
remains an asymmetric one. In the US, providers and commissioners are pretty evenly matched when it comes to the collection and use of data. They go head to head all the time. Sometimes one side has a temporary advantage, sometimes the other. For a long time, managed care (commissioning) organisations were on top, but public opinion has helped hospitals regain the advantage in recent years.
PROVIDER VS. COMMISSIONER The provider interest has dominated the NHS throughout the 20-year history of the ‘internal market’. Hospitals have always been in a stronger position at the negotiating table vis-a-vis their commissioning peers, not only because their management teams have professionalised faster, but because they have been able to create and sustain a single-minded point of view about what they want to achieve in their localities. As a consequence, they have created a business approach that takes in lots of performance data. They know it’s the responsibility of the hospital board to do its best for its patients and staff; but this is, of course, not the same as for patients and the local population, which is the responsibility of the commissioner. And in negotiations with PCTs they have not hesitated to use their information advantage with sometimes devastating effect. I’ve witnessed a number of occasions where a push by an acute trust for more funding has left other parts of local provision – mental health, for example – significantly depleted.
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Where once ROGER HYMAS was booed for even suggesting the NHS had something to learn from America, now, finally, commissioners are listening. Here he discusses big data and how the Yanks are leagues ahead
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