All health systems in the developed world are grappling with the challenge of providing increasingly complex, expensive, health services within finite budgets.

But work by the Healthcare Financial Management Association’s American sister organisation has shown the similarities between our predicaments don’t end there.

‘What is needed in our system perhaps more than in the US is public support for change and public understanding’

Healthcare costs in the US have begun to outpace quality improvements, creating a “value gap”. In response, HFMA USA undertook a “value journey”, to investigate how that gap could be closed.

Its research into 35 stateside hospitals and health systems found many problems that will be familiar to those of us working in the NHS:

  • inflexible organisational cultures;
  • difficulty in aligning clinicians to organisational goals;
  • expectations of diminished future revenue;
  • uncertainty about future payment models; and
  • lack of “patient accountability”, with some payment arrangements that allow unrestricted access to services encouraging inappropriate use.

The US response has been to review organisational portfolios, looking at centralising more-specialised services, redesigning pathways and revising the role of small hospitals.

Familiar picture

Organisations are devising strategies for chronic care patients who use emergency departments for non-urgent care. Many are thinking about mergers and alliances. Standalone rural hospitals will face particular challenges and the larger hospitals are seeking ways of securing the referral base.

‘The public cannot be blamed for resisting service changes introduced as the result of “crises” in their local hospitals’

Sounds familiar, doesn’t it? But how does all this square with competition in the bastion of the free market? The approach is about creating systems that together are able to offer high quality, comprehensive services to defined populations at reasonable cost.

In the UK increasing sub-specialisation, changes to medical training, pressure to publish patient outcomes, litigation, rising patient expectations and, of course, pressure to reduce costs are leading trusts to the same conclusions as their US counterparts.

Dangerous territory

But what is needed in our system perhaps more than in the US is public support for change, and public understanding that many smaller hospitals will struggle to provide safe, clinically effective and cost-efficient services across the full range. The fortunes of Mid Staffs and South London Healthcare have again exposed the difficulties of making that case.

‘We need to take the public on the same value journey, to help people understand the problems facing a modern health service’

The public, however, cannot be blamed for resisting service changes introduced as the result of “crises” in their local hospitals. People are liable to feel “crisis” is being used to force through changes that would otherwise be unacceptable.

What we need is to take the public on the same value journey, to help people understand the problems facing a modern health service. This must include demonstrating the real challenges faced by our medical and clinical colleagues in ensuring they deliver safe and effective services, and showing that improved outcomes are linked to their seeing a critical mass of patients.

Dangerous territory, but one we will increasingly have to journey.

Chris Calkin is chair of policy at the Healthcare Financial Management Association and a consultant.

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