How much do you have to prove? A tale of the modern NHS marketplace

I took a voluntary redundancy from the NHS in 2011. Since then I have run a small company providing clinical psychology services. I mainly do expert witness work for the family courts, which I have blogged about before, but we also offer therapy, consultancy, training, research and other services.

In 2012 we bid for a grant from The Health Foundation to offer brief psychological interventions into the diabetes service for people of all ages at the local hospital. We wanted the bid to be innovative, and so we were determined to think differently about how we structured the service and hoped for it to be commissioned. We decided we would use the grant to set up a Social Enterprise to deliver psychological services, and that we would aim to get commissioners to agree to fund the service in retrospect according to the outcomes we achieved. You read that right – we planned to deliver a service for no cost in return for an agreement to pay for the outcomes we achieved. No more “spend-to-save deadlock” in which the NHS can’t invest in the things that will save money; we were providing the service for no cost to the NHS during the project period and offering to continue to do so, based on retrospective returns dependent upon whether we improved people’s lives and saved costs for their medical treatment. We also agreed to survey the level of mental health need amongst the population using the diabetes service at the hospital, and look at whether this related to their blood test results (which are the best indicator of adherence to medication regimes and lifestyle advice, and of physical health prognosis).

Diabetes is a hot topic because it is predicted to “bankrupt the NHS” due to the rising incidence and cost of treatment. It already costs the NHS £10 billion to treat nearly 4 million people with diabetes in the UK, and this is set to rise to £17 billion by 2035 as the incidence increases to 6.25 million diabetics. Once the loss of working days, early death and informal care costs are factored in, these costs more than double. Even more shocking is the fact that 79% of this expenditure is preventable, if patients followed the lifestyle advice and medication regimes recommended. Studies consistently show that around 40% of people with diabetes have mental health problems, and around 14% of this cost is prevented if there are services to support the psychological health of patients. That is £2.4 billion pounds of avoidable NHS expenditure per year, and around £3.2 billion more in the wider economy. Yet psychological services for people with diabetes are far from universally available.

The Health Foundation loved our proposal and gave us a £75,000 Shine Award to deliver it.

We set up our Social Enterprise which we called Evolving Families. The name is designed to reflect the fact that people change in their thinking, behaviour, learning and roles over their lifespan (and a fair chunk of our work is with adults reflecting on childhood, with parents or with young people whose family circumstances have changed). A Social Enterprise is a business that is run for the benefit of a community, society or environment, and invests the majority of their profits towards that good cause. Our Social Enterprise was designed to invest in delivering psychological services that might not be otherwise funded, like doing research or subsidising people who could not afford to pay for therapy but were not eligible to get what they needed on the NHS.

We used our agility as a small company to employ staff very quickly, and we were up and running for the project to start on 1st Jan 2013. We accepted 65 referrals in the following year (52 adults and 13 children), and closed the project at the end of December 2013. Of those 48 (36 adults, 12 children) attended for psychological therapy and completed pre and post therapy measures, with an average of 6 therapy appointments each. We were able to see people at their homes, at schools, in the community and in our offices. We saw people in the evening if this was more convenient. We went to multi-agency meetings about some of the young people. And most importantly we didn’t have defensive service boundaries – if we felt we could improve psychological wellbeing then we offered services that didn’t directly relate to their diabetes or mental health, for example cognitive assessments, advice about employment, exploration of the impact of neuro-developmental difficulties or sensory impairments.

We screened 750 adults and 100 children who attended the clinics, using the PHQ-SADS (a measure of depression, anxiety and stress used in the IAPT scheme) and the Problem Areas in Diabetes questionnaire. This showed a highly significant relationship between all areas of mental health and HbA1c (the blood glucose score that is the best indicator of how well controlled the diabetes is). There was a very high rate of mental health problems, including a very worrying level of suicidal ideation in both age groups. There was also a very poor level of diabetes control; only 20% had an HbA1c score in the range considered to be optimal (<7) whilst 60% had dangerously elevated levels (>7.5), indicating that this hospital clinic serves a very complex and risky population group.

After the year was complete, we had clear evidence that our service was helpful and cost effective. We made a significant change to participants lives – not bad for 48 people getting  an average of 6 sessions of psychological therapy. Their mental health improved markedly. Fifteen people who were having frequent suicidal thoughts were no longer suicidal, 19 A&E visits in the months before therapy were reduced to 1 in the same number of months after therapy, 30 ward admissions in the same period were down to 5. The cost saved by this reduction in physical treatments was greater than the project cost to deliver. All in all we had pretty impressive results for providing psychological interventions at a cost per head that was lower than IAPT. We were Highly Commended in the HSJ Efficiency Awards.

But did commissioners bite our hand off to take up the offer of paying for the service based on the results it achieved? No. We couldn’t even get to talk to commissioners in person. The hospital told us to talk to the CCG, the CCG told us to talk to the hospital. They told us they need fixed cost contracts to put in their budget, not this outcome based stuff. The contract value is too small to be separately commissioned, and we are outside providers. The service closed to referrals a year ago, and although our service users are passionate about the need for the project and the impact it made on their lives, nobody seems to be listening. So we’ve written a business case and given it to the various service managers at the hospital, and we’ve presented our results locally and we wait, with dwindling hope that it will be picked up at some point in the future. Maybe in the next financial year. Maybe when they reconfigure the diabetes provision.

So I ask: how much do you have to prove in the modern NHS marketplace? If we can deliver a highly effective, life-changing service, and save the NHS more than it costs within the financial year, and we are prepared to accept payment in arrears based on the outcomes we achieve, what more can we do?

Video flash of powerpoint showing outcome data for the project is here: https://www.youtube.com/watch?v=sdyVfGOkdD0

Service user comments about the project are here: https://www.youtube.com/watch?v=KsQDgs-yDq4

8 thoughts on “How much do you have to prove? A tale of the modern NHS marketplace

  1. B.Jameson says:

    Don’t take this the wrong way, but Good! it should be difficult for you and anyone else to take public money to put into private pockets. The models of running a business and running a public service are incompatible and rightly so. Private business is the scourge of the NHS & no matter what ‘good’ you may feel that you have done, there will be 10 other companies waiting to copy you and cream more money from the NHS. The NHS trained you and now you wish to help destroy it – SHAME on you.

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    • You couldn’t be more wrong!

      First, it isn’t putting public money into private pockets. It was a research grant run in collaboration between an NHS trust and a social enterprise that saved the NHS money. No NHS money. No private pockets. “No matter what ‘good’ you may feel you have done”? We changed the lives of 48 people, and stopped 15 of them from being suicidal. That shouldn’t have a price, but we did it whilst costing the NHS nothing and saving them money in medical treatments for those patients. Before us there was no service for these patients, and now there is no service for these patients. We didn’t compete against an NHS provider in any way.

      The NHS trained me, and I worked for the NHS for 16 years and planned to spend my entire career within the NHS. However, after the health marketplace was introduced it then treated me (and many other people I know who were equally loyal to the NHS) very badly. Due to political changes the NHS stopped being a single awesome organisation and became a set of private companies sharing a brand name, which each focus on profit and throughput and delivering the minimum contract specification. I’m terribly sad about that. But I can’t undo it. And I believe that going forward from where we are, the NHS needs to focus on delivering measurable improvements in health and wellbeing in a cost-effective way, not just focusing on throughput. NHS money should pay clinicians to deliver services to patients who need them. Not fund contract lawyers and marketing/bidding teams and constant organisational change. As soon as it does I’ll be back fighting from the inside, but for now I can work in a way that fits my ethics better in a social enterprise.

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  2. Kieran says:

    I wish there was more people like you in Ireland!!. Ireland is behind in mental health sadly and no one seems to lift a finger to do anything about it, especially in rural areas. The HSE is ten years behind compare to the NHS and funding for any mental health project is nearly impossible.

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  3. Crow says:

    The new NHS doesn’t listen, I think, because so many staff are scared of their own jobs and under so much pressure to do what they don’t want to do that they are angry. In their anger they are sticking to a “work to rule” way of working that ditches rational thinking in favour of apparent compliance with targets and statistics to keep managers & politicians happy. This results directly in good people like yourself from helping patients. We cannot run a health service where the priority is financial expediency rather than the health of those who need help. It’s impossible. You simply get a crazy selfish frustrating useless service like the one we now are beginning to see. Unless professional very quickly have the courage to take a major stand (en mass) against government interference, while the public are still on their side and will back them up, this will all get much worse very quickly – we are looking at the last days of the NHS. It is a grand experiment designed to try to keep a large enough sample of the public healthy enough to work – nothing more. I seem to remember if was doctors who fought against the Labour Government in 1948 when they tried to set up the NHS. It seems to me that it is doctors who refuse to fight against the current government’s intent to eradicate the NHS that will be responsible for its death. The British Medical establishment always take decades to achieve implementation of results from new research. In 2 years time the NHS will be 70yrs old – it has dementia, heart failure, diabetes, cancer and mental illness – it is terminal. Will our doctors euthanize it or save it? I guess it depend on where their own short-sighted interests lie.

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    • The problem is that professional bodies become behemoths – slow to move and strangled by their own processes – and professionals are so overwhelmed with the demand that they can hardly see beyond keeping their own hamster wheel spinning for their patients to the bigger picture. Meanwhile the media blames the vulnerable, and implies that wealth (and even health) is a meritocracy.

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