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Getting healthy, not just getting better

8 June 2016

Gemma Self writes about how health care is funded - and how a future of health service providers being paid to keep people well might look. Gemma is Director at Reimagine Health, a small consultancy focused on redesigning incentives in healthcare to focus on patient outcomes and prevention across the UK. She is an alumna of the NHS Graduate Management Training Scheme and has held a variety of leadership and implementation roles within healthcare. This is part of a series of blogs, where key players in Bristol's health sector write about a health related subject of their choice. If you want to contribute, email

How changing what we pay for can radically improve healthcare in Bristol

Imagine a healthcare system in Bristol that is designed to keep us healthy, and is paid to achieve that.

How organisations delivering healthcare are currently paid is a complex picture and many of us don’t think about paying for our healthcare; generationally there are few people left who have had this experience in the UK.

How we as a society measure health and invest in keeping people healthy, however, can have a significant impact on the services we receive.

Currently, every time we use a service delivered by the NHS, that organisation is paid on our behalf. Some are paid upfront to see a predicted number of people. Some are pay-as-you-go, for every day someone is in hospital and for the specific type of test or procedure they have done. Pay-as-you-go payment is quite sophisticated and has led to a significant reduction in waiting times in hospitals.

If a hospital is paid for every procedure and night in a hospital bed, from an economic perspective it is in their interest to keep people rolling through their doors. (It is of course, not so simple, as hospitals already have financial incentives to not keep people in hospital and healthcare’s sole purpose is to ensure people get better.)

Currently, our health system isn’t paying for what people really need - to be healthy, physically and emotionally, and ideally, not get ill in the first place. So we are in a state where we need to find a way of paying for what we, our families and friends need.

We are moving towards a future where there are bundled payments for health – where providers are paid on an annual basis to deliver any services needed to keep people healthy. They could then get a bonus reward when there is evidence that this has been achieved. This means that the provider delivering the service is required to think about working with other organisations to prevent ill health, or else they have to fund the impact.

You may be the son, daughter, grandchild or other relation of an older person with a number of health conditions and who is living alone. They will probably visit their GP and hospital services over 10 times per year, sometime requiring an ambulance. They may go to a group run by a local voluntary sector provider to help them to meet others in the area.

Currently the local system pays separately for each of those services and interactions. So there is no financial incentive for any of the providers of those services to work together or prevent any future episodes of ill health. They treat an issue as it arises but then see the end of that episode as a success. Yet, most healthcare professionals can predict the future healthcare needs for that individual.

Imagine what a future could look like if organisations were paid to ensure that older people spent more time at home, felt in control of their health, had an agreed individualised care plan and their blood pressure was reduced.

In this scenario, the hospital needs to think about working with the GP and the community health team to proactively support the patient to know what to do about all their medication. Perhaps the lead organisation now responsible for older people’s care buys in some transport to ensure that patients who struggle to get to their appointments are taken there. If more than an anticipated number of older people go into hospital due to a need that was preventable, the organisation responsible could have to absorb the cost, recognising that their service wasn’t working. Innovations and investments to prevent ill health would rapidly ensue.

This whole concept is Value Based Healthcare. With the principle that instead of planning for and delivering hospitals based on volume (number of patients and how long they wait), a whole system moves to measuring health on the basis of whether patients are healthy and happy.

It’s a future state that focuses on getting people with long term health conditions to stay as healthy as possible, for older people to spend more time at home and for people with serious mental illnesses to be able to work.

There are very few alternatives that provide such a rosy picture for how healthcare could be delivered in the future. With a growing momentum for this approach both in the UK and around the world, Bristol is also thinking about how different organisations can come together to focus on these goals.

With the city’s ethos towards locally produced innovation, social improvement and a strong moral standing, we are in the perfect climate for creating a bright future for health.

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