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Integrated care needs incentives that matter to clinicians as well as accountants
John Copps argues that successful integrated care requires us to understand the personal motivations of NHS staff, as well as getting the financial flows right.
Integration is the holy grail of NHS reform. A succession of national strategies – from the Five Year Forward View to the recent NHS Long Term Plan – imagine a yet-to-be-realised vision of joined up services with seamless pathways of care.
One thing that everyone agrees on is that a key barrier to this vision is the lack of alignment between incentives for different parts of the system. At its most extreme, this leads to situations where what is in one organisation’s interest is squarely against the interests of another. More commonly though, the differences are subtle. But across a pathway of care subtle differences add up, and can end with everyone pulling in different directions.
The most obvious competing incentives are financial. For example, hospitals tend to be paid for the number of patients they treat – so the more ill people and the quicker they can be discharged, the more money comes in. In contrast, social care is funded from a fixed local authority budget – so the fewer people requiring care, and the fewer people leaving hospital with support needs, the better off councils are.
But just thinking about incentives from a financial point of view tells only half the story. Insights from behavioural science tell us that motivations are complex and often deeply personal. Speaking to clinicians in different parts of the system and you see a day-to-day motivation that in more in line with this view than with classical economic thinking.
I think back to some work I did with clinicians working on a heart disease pathway in Manchester. A change to the way services were delivered meant that they were ready to accept a level of personal cost and inconvenience if it led to a better service for patients. The incentive to provide even better patient care was clear as day. They were motivated by a sense of duty to patients and pride at a job well done.
But this incentive didn’t work equally well for all clinicians because it was blunted by a lack of information. A series of conversations with a group of diagnostic nurses stuck out for me – they were no less passionate about their services but saw patients a handful of times and never found out what happened to them. If anything could make their jobs more satisfying, they said, it would be ‘to know what happened to our patients’, including ‘whether they lived or died’.
Successful integration requires paying close attention to incentives – both organisational and individual, financial and non-financial. The NHS needs to become a system that aligns financial flows to patient outcomes and makes these outcomes more visible to clinicians.
To create a more joined-up NHS, we must look beyond the money, understand what matters most to staff and put outcomes at the centre.
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