Productivity vs Busyness in Primary Care
Although a long-standing matter for discussion, the concept of productivity in the NHS as a whole is currently extremely topical, after the Chancellor’s promise of an extra £22BN for the NHS . Although many authorities and individuals have an opinion, they are not always informed as to the detail.
Some expressed points of view are challenging (and borderline insulting) from the perspective of clinicians due to potential confusion between “productivity” and “busyness.” There can be resentment if it is felt that the lack of “productivity” implies that they are not busy doing stuff. From the external perspective, there is confusion between “productivity” and “cost-effectiveness,” predicated on a lack of a shared understanding of what the output, as valued by the user, of a health system actually is.
Productivity is the efficiency of production of goods or services expressed by some measure. In the subject of healthcare, it is pertinent to consider carefully what is “the service.” In most assessments (e.g., those from York University, the Institute for Fiscal Studies, and that used by NHS England board papers), “the service” is a clinical interaction – In primary care “an appointment”.
Reflection allows us to think from our personal experiences that when we are, or fear we may be, unwell, we seek resolution. We do not just seek an appointment; we seek for our health to be improved and our anxieties to be allayed. The danger of not appreciating this point is illustrated, perhaps unfairly, by recent cases involving physician assistants. This is not the same as the recent NHS drive in primary care to minimise queues (“The 8.00 rush”) by providing more appointments, inconsiderate of the capability of these appointments to address healthcare issues.
These parallel lines of thinking open the door to how NHS managers and other citizens may generate contrasting priorities.
Defining the True Output of Healthcare
If the creation of an appointment is the only thing that is counted, then it becomes the only thing that counts. In a health system that has to make choices over priorities, as every health system in the world does, the sensible choices are to prioritise interventions that give the greatest gain per pound spent. This allows us to introduce the concept of “value.” What are the interventions that are most valuable?
If we agree that influencing health is what clinicians and health care systems should do, how can we define in health economic terms the output of the health system? The answer to that is:
The output of the healthcare system is a lessening of the degradation of health status in individuals that would otherwise occur.
This definition is built on the concept that everybody who is born (most, but not all, with very good health potential) is on a trajectory towards death (by definition; with no health). That is the natural course of events, and health systems intervene to keep people as healthy as possible for as long as possible. This trade-off between quality of life and duration of life is explicitly managed by health economists in the concept of QALYs and DALYs. These have been used in the United Kingdom by NICE to make choices about how we invest, or perhaps more difficultly do not invest, taxpayers’ money in differing technologies or medications. Choosing where to spend the investment promised in the latest budget is exactly the strategic choice faced by the health system.
We can therefore see that a managerial system that prioritises input based “productivity” measures will necessarily be less effective in its mission than one that seeks output based “value” measures. Assuming of course that the mission is “the preservation of life and the relief of suffering” rather than purely keeping lots of NHS employees occupied. This effect is compounded in publicly funded state run system which prevents individuals from seeking their personal vision of what is valuable.
Understanding the Value of Primary Care
NHS information systems, such as they are, are based on the need to keep track of financial flows based on the needs of NHS managers created by the “payment by results” regime. As primary care is contracted under a capitation basis, there has been no managerial requirement for tracking demand or capacity (as opposed to a concern about an implied excess of demand over capacity). This information asymmetry has produced a system where spend and investment choices are made, and have been made, on the principle that primary care capacity is both infinite and cost-free. The outcome of this is asymmetrical prioritisation of investment in the secondary care system rather than the primary care system. To see the strange results this brings, see the planned workforce expansion in secondary care doctors rather than those providing primary care. Does this matter?
Primary Care
What is the value of primary care? There are two distinct lenses to approach this problem, firstly that of the patient and secondly that of the healthcare system.
From the patient perspective, primary care clinician activity prolongs longevity and reduces the burden of disease by both deploying skills within their practice and by referring onto other services. Primary care acute care offers vast amounts of same-day appointments for patients who view their problems as urgent. It provides diagnosis and treatment for these patients. It provides the majority of chronic disease management funded predominantly through the quality and outcomes framework. Critically for many patients, it makes no technical medical intervention but reassures patients around the natural history of any conditions they may fear they possess. When equipped with the secret superpower of continuity, it can hit the magic triad of:
- Superior outputs.
- Cheaper costs.
- Increased patient and clinician satisfaction.
But what about the position within the healthcare system? In systems that accurately track the cost of a patient through the healthcare system (i.e., unlike those in Britain which ignore the true costs of clinical labour in primary care), primary care is cheaper care. Multiple health economic reviews observe that using international comparators, the systems that prioritise primary care over secondary care get better results for their money. Patients that cross from primary care into the secondary care sector become very much more expensive, so to the healthcare system a valuable general practice is one that refers little. The same argument applies to prescribing.
From Cost-Effectiveness to Value-Based Care
This produces the fascinating concept of “the inappropriate referral” from primary care to secondary care. In all my reading and experience, the only useful definition of an inappropriate referral is “a patient whom the consultant would refuse to see privately.” And I have had occasional arguments like that with patients who wish to see a consultant for a condition which is outwith the consultant’s skill specialty (e.g., a bowel condition seeking an appointment with a gynaecologist). Most managerially driven conversations around referral rates are either implicitly or explicitly driven by the payment by results rate card, i.e., just spend less in secondary care, rather than considering the value to patients and the total cost of care. It is worth noting that 11% of negligence claims in England are as a result of a perceived failure to refer. So, there can clearly be both too much and too little referral.
In summary, where does this take us?
The argument is for a focus on the health economic concept of value rather than the managerial concept of cost-effectiveness. The health economic approach allows us to make choices for the best spend of the limited taxpayer’s pound. We can approach the concept of value through the two differing lenses of value to the system and value to the patient and understand that they are in fact interrelated. To get maximum value, we must chart the cost of the patient around the system and seek to minimise total cost rather than adopt a strategy of minimising visible cost in one sector.
