The advent of outcomes based commissioning has been hailed as a vital step towards a world in which the fragmentation of services and ever rising acute activity blamed on payment by results are banished.

But could we just end up swapping one load of perverse incentives for another?

‘What could possibly go wrong? Well, many of these metrics haven’t been identified or designed yet’

It has been noted that in the planned Bedfordshire musculoskeletal contract, only 5 per cent of the cash involved will actually be outcomes based.

This could be seen as prudent given the untested nature of the deal and the metrics used to measure the outcomes.

But it also raises the question of whether the prime contractor is taking on enough risk.

Patient feedback

With only 5 per cent at stake, couldn’t the lead provider just screw down on what it pays its subcontractors?

If they can save 5 per cent of delivery costs that way, the prime contractor could insure themselves against the financial risk without having to give outcomes a second thought.

For this reason Nick Hicks, co-founder of outcomes based contracting consultancy Cobic, says making 20 or 30 per cent contingent on outcomes would be best.

‘Contractual wrangles over who said what, and what they meant, don’t seem far fetched’

However, Diane Gray, director of strategy and system redesign at Bedfordshire Clinical Commissioning Group, points out that the other 95 per cent of the contract value is still linked to clinical quality. For instance, the lead provider could be found to be in breach if they are found to be failing to deliver against the NHS constitution, meaning it couldn’t just restrict access to services.

There will also be patient feedback indicators built into the deal, which commissioners hope will enable them to hold the lead provider to account if people’s experience of services suffers. Intelligence from GPs will also be used.

Legal tussles

What could possibly go wrong? Well, many of these metrics haven’t been identified or designed yet. But as soft intelligence is going to be used, one might imagine there will be dispute over whether a provider is in breach of contract.

Contractual wrangles over who said what, and what they meant, don’t seem far fetched.

Dr Gray says her CCG is looking to enter into a partnership as much as a hard nosed business contract. If outcome based commissioning is to become the norm, the pioneers of the method will have to prove that, when performance falters, the maturity of the relationships involved can prevent a dispute from descending into an endless legal tussle.

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