Comment / Time to pick up the pace of change?

It is natural to be impatient for change in the NHS. If you’ve identified how services can be improved – or could be provided at lower cost – why wouldn’t you want to switch those changes on immediately?

Things are rarely so straightforward – changes take time for a reason, particularly in the public sector where evidence, governance, consultation and transparency are vital. There is a balance to be
struck always between getting it absolutely right, using the right process and getting to the finish line as quickly as possible.

However, the service could really use a burst of speed in a number of areas.

Let’s start with the tariff, with the latest version for 2015/16 published just before Healthcare Finance went to press. Monitor and NHS England both acknowledge the need to ‘encourage transition to new payment designs at pace and scale’. Their approach of asking local health economies to test new payment approaches, rather than mandating new systems before they have been tested, makes a lot of sense.

But the reality is that many health systems have been struggling with old currencies and prices that are no longer working for them. The marginal rate tariff for emergency admissions – based on historic activity baselines that take little account of increasing demand – has been a good example. While it has been tweaked, there are other examples.

Some finance directors in the most recent HFMA NHS financial temperature check survey would prefer to see a return to cost and volume or even block contracts instead of the current payment system.

Tariffs may not be the prime motivator for change, but surely the real answer is to get systems that at least encourage new ways of working and provide appropriate funding for those services once in place.

There has clearly been a lot of work on payment approaches and tariffs in the past few years. But there’s a view that we are currently patching up the existing approach, perhaps even putting off some potential improvements – the implementation of the revised HRG4+ currency, for example.

The service really needs to start seeing some of the fruits of this labour put into action, whether that be dual capacity/activity tariffs for urgent care or year-of-care budgets for long-term conditions.

The same can be said for costing. It’s been two and a half years since Monitor identified the need for more robust cost data. Of course there have been improvements. We’ve seen the first national collections of acute patient-level cost data and the HFMA Clinical costing standards have continued to promote best practice. But there is a feeling that we could have got further, faster. However, it is good to finally see an ambitious timetable and clear direction of travel confirmed for this.

This brings us to the connected issue of transformation, which is where acceleration is absolutely central to meeting the current service and financial challenge. It was a point that finance directors made in the last temperature check survey and they reinforce this in the latest report.

There are examples of transformed services, but arguably not yet at the scale that would meet the activity and efficiency demands needed. The speed of progress on transformation is tied to the development of tariffs and better cost data. Maybe once everything is in place, we’ll see more rapid progress. But a good example of transformed services working at scale in a replicable way would do the service wonders right now.