Dr Minesh Patel
Senior Leadership Team, NAPC
As clinicians, we’re used to thinking about what’s best for the patient in front of us. The harder question — the one the new NHS landscape is forcing us to confront — is what’s best for the whole population we’re responsible for, when the money simply doesn’t stretch to fund everything that could help someone.
That’s the real challenge behind three big changes happening at once: Integrated Care Boards (ICBs) taking on strategic commissioning, Integrated Neighbourhood Teams (INTs) delivering proactive local care, and some trusts becoming Integrated Health Organisations (IHOs) holding capitated contracts for a whole population. All three only work if someone is asking a hard question: are we spending this money where it does the most good? A new leader at the helm of government, may need to make some bold choices of how best we spend our finite resources across all public services from health and social care to housing, education and employment and other civic services to gain maximum benefit.
It’s not just about being more efficient
We’ve spent years getting better at doing the same things faster and cheaper — efficiency. Sir Muir Gray’s work makes a different point: the bigger prize is often in moving resources between services altogether, not just running each one better. If shifting money from one programme to another would do more good overall, then we weren’t spending it in the right place to begin with. That’s a much harder conversation than efficiency, but it’s the one strategic commissioning is now asking ICBs to have.
This isn’t new territory — the Centre for Health Economics at York has spent decades building the tools for exactly this (cost-effectiveness, opportunity cost, the NHS funding formula), and countries like Canada and Australia have used similar approaches to work out what to stop doing in order to fund something better.
Neighbourhoods need this too
It’s tempting to think this kind of thinking belongs at the top of the system. But INTs are being asked to do the same thing locally: understand their population’s risk and needs and decide where limited neighbourhood resource and staff time will do the most good. Falls prevention, frailty support, social prescribing — these all compete for the same pot, and prevention usually loses out to the more urgent problem in front of us, even when it would do more good in the long run. Wales’s Prudent Healthcare programme shows what it looks like when this kind of evidence is put in front of clinicians and neighbourhood teams directly, rather than kept in a finance office somewhere.
Providers need it too, not just commissioners
Here’s what’s changing: as trusts take on IHO contracts and become responsible for a whole population’s health within a fixed budget, this stops being someone else’s job. Providers will need to understand, for themselves, where an extra pound does more good — in the hospital or out in the community — because they’ll be free to reinvest any savings back into better care.
The bottom line
The evidence from the UK and abroad says the same thing again and again: resource decisions made openly, with good evidence behind them, lead to better outcomes and are easier to defend than decisions shaped by habit or whoever argues loudest. A deeper understanding of value based outcomes is often displaced by immediate priorities and directives.
As commissioning and provision are redesigned at the same time, the systems that do well will be the ones that build this kind of thinking in everywhere — ICBs, neighbourhoods and providers alike — rather than treating it as a specialist function called in occasionally.
The real question isn’t whether we should be doing this. It’s whether we can build the skills and evidence base fast enough to keep up.
Read more about providers and neighbourhood health:
Discover how provider organisations can support neighbourhood health and population-based care in the NAPC publication, Providers and Neighbourhood Health.
