Are we crippling the NHS with a cost-based approach to patient care?

In my work, I often see examples of the NHS entirely focusing on the money.

If a patient is prescribed a drug that costs £200, but there’s an alternative for £20, all too often, it’s the one for £20 that is dispensed.

But that sometimes forgets about the patient on the end of that decision. If they’re being prescribed a drug or referred to hospital by a healthcare professional, the patient clearly has health needs that should be addressed as quickly as possible. In essence when a healthcare professional prescribes or refers they are pursuing an outcome for the patient. The sooner that outcome is achieved, we release workload pressure.

And that often gets lost if all we focus on is the money.

If people are ill, they don’t stay at home

I saw a tweet recently from one of my contacts, Craig Nikolic, chief operating officer of Together First CIC, Barking & Dagenham’s GP Federation.

His tweet, directed at NHS commissioners, read: “If you plan to reduce hospital attendances by increasing referral BaRS, those patients don’t magically get better. They go to general practice, and you’ll probably see them as more ill and more expensive patients later. Burying your head in the sand is not a credible strategy.”

I completely agree. Unwell patients don’t sit at home, they head straight back to the GP, often repeatedly. This is regularly completely missed when money becomes the focus over patient outcome.

By definition, the most expensive prescription is the one that doesn’t work because that ends up costing more in the long run, with more appointments, referrals and often admissions that result. It is a false economy.

Sub-optimal treatment at the heart of the problem

If we prescribe a drug at £20 and the patient doesn’t get better, they don’t go away. They come back to general practice. Then, because they are often restricted on what they can prescribe, they end up referring them into very expensive outpatient appointments to have a more expensive treatment prescribed.

One of my best projects running at the moment is in East Sussex, with a hospital trust with four hospital consultants from different specialisms and a GP who is working on behalf of a primary care network which is fully engaged with the project.

The driving force behind this project is GPs frustrated by backlogs in outpatients, leading to patients spinning back into the practices where the GPs can do nothing with them. Outpatient departments are overrun. They can’t cope with the volume of people sent to them, which creates a backlog and sends the patient back into general practice.

They are looking at the problem together and found that 80% of those referrals were driven by sub-optimal treatment. And some of that sub-optimal treatment was driven by the fact that the GPs were restricted in what they could and couldn’t use – a cost-driven, rather than an outcome-driven, list of medicines.

Collaboration reduces everybody’s workload

Unless we are 100% happy with the current outcomes we’re achieving – in terms of workload, the number of referrals, the number of appointments, the number of admissions – then we can’t be happy with a cost-based approach.

As Craig said in his tweet, some of the patients that we’re not able to refer end up becoming much more sick. And they end up being picked up by ambulance and taken to hospital for a very expensive admission when a lot of that could have been avoided if we had an outcome-focused approach.

In simple terms, we’re prescribing A to get to B (the desired outcome).

• B (the desired outcome) doesn’t happen, so what’s the next step?
• Try C to get to D.
• But D hasn’t happened either.
• So we prescribe E to try and get them to F, and if F doesn’t happen at that point, we can refer them to hospital.

Now we’re referring a patient who has been fully and appropriately treated by General Practice but is now at the point where they definitely need a referral, having worked through all other obvious avenues first.

The East Sussex project focuses on collaboration, support, encouragement, training, and education. Upskilling within general practice helps them better manage the patients at an early stage. It reduces the GP’s workload because the patient gets a better outcome, and it reduces the hospital workload because not as many patients need to be referred to them.

Spending more might be cheaper in the long run

So – if you become completely focused on cost, you lose sight of the fact that the patient needs an outcome.

Sick patients don’t sit at home, they go back to their GP repeatedly, consuming appointments, when there’s very little that can be done with them because the decision’s already been made to refer them into secondary care. But secondary care services are too overloaded to take them yet, so they go home, feel unwell and go back to their GP.

If you’re experiencing that, my encouragement is to step back, put the cost to one side and actually look at the outcome you’re pursuing on behalf of the patient.

If you’re working from a point of view of cost and looking to spend the £20 rather than the £200, ask yourself if the £20 is going to get you the outcome you envisage. Because if it isn’t and spending £20 now could mean spending £400, £500 or £600+ further down the line, then surely it would have been better to spend £200 in the first place rather than driving all that workload, all those referrals and all those admissions into secondary care.

It’s not easy to achieve but it’s very doable and a great outcome if you focus that way. I’ve got lots of examples from up and down the country in my work with the NHS and Pharma, MedTech and Appliance companies of collaboration which has led to great, cost-effective outcomes.

They are not focused solely on the acquisition cost. They’re focused on the complete acquisition cost of the patient care, which is often missed completely when all you focus on is the drug, device or technology acquisition cost and forget the outcome being pursued.

So, ask yourself this – how much is that £20 solution really costing you – and the patient – in the long run?

Fed up of pulling in different directions? Scott McKenzie help GPs, PCNs, GP federations, and Integrated Care Systems tackle their communication and process challenges to build sustainable and resilient practices that produce better outcomes for all. If you’d like to find out more, schedule a call today.