Improving the patient experience: 5 things we can learn from Geisinger

Measuring and improving the patient experience is vitally important. The Royal College of Physicians, for example, say patient experience should be valued as much as clinical effectiveness, and patient experience is one of Lord Darzi’s 3 quality criteria.

However, patient experience is highly subjective and that makes it difficult to measure.

As part of Monitor’s focus on incentivising better patient care through the payment system and other regulatory functions, we are speaking to leading providers and commissioners across the world about how they define, measure and improve patient experience.

Here are 5 things we learned from Dr John Bulger of Geisinger Health System, a leading not-for-profit insurer and healthcare provider based in the US.

1. Focus on what matters to patients. Patient experience can refer to many different aspects of care, but in Dr Bulger’s experience, some of the most important questions for patients are: did staff treat me with respect, was my pain minimised, was there good communication with me and my family, was it convenient. The next step, says Dr Bulger, is to move towards patient-reported outcome measures, rather than just measuring overall satisfaction. This means asking the patient, in the example of a hip replacement, how much joint pain they had before and then after, what was their quality of life before and after.

2. Ask patients. Geisinger uses an external company to send conventional survey forms out to patients who have been in its hospitals or clinics.  It has also started using online surveys.  The questions cover staff friendliness, waiting times, ease of booking appointments, interactions with doctors and nurses, food, cleanliness and so on.

3. Have dedicated staff. A part of Geisinger’s quality and safety division is already tasked with patient experience, and the organisation is in the process of hiring a chief patient experience officer, a role that is becoming increasingly common in US hospitals. Data analytics experts are also on hand to help organise the data and make it available to staff. For example, Dr Bulger says, a hospital nurse can log in and see how his or her floor is doing at any given time, and how patients have rated their experience. Encouraging transparency, where each floor can see how the other floors are doing, means Geisinger can try to understand why a certain group is doing better or worse than others and spread the learning.

4. Look for insights. Dr Bulger says he was surprised to find that doing 2 things together – which individually had only a minor impact – could make a big difference. For example, when Geisinger tried coupling hourly rounds by nurses with daily visits by the nurse manager, they discovered it significantly improved patient experience, whereas each measure on its own hadn’t had much effect.

5. Incentivise clinicians. Geisinger gives bonuses to doctors and nurses that are related to patient experience and survey results. The bonus works out to around 1 to 2% of their salary, not a huge percentage, but Dr Bulger says it gets staff’s attention and sparks debate about the best way to measure patient experience.

Dr Bela Prasad is pricing development lead at Monitor. She spoke to Dr John Bulger, chief quality officer at Geisinger. Further interviews are planned with other health leaders from around the world.

What we heard about the 2015/16 national tariff proposals

Our last blog described how the proposed 2015/16 national tariff aims to help the health sector bridge the gap between growing cost pressures on the NHS and a flat budget in real terms.

To develop our proposals, we relied heavily on the knowledge and expertise of people in the healthcare sector.

This blog explains how we engaged with the sector and what we heard.

Supporting parity of esteem between mental and physical health services

Monitor is strongly committed to supporting parity of esteem between mental and physical health services, and is not recommending cutting budgets for any services.  In fact, expenditure on mental health services across the NHS- trusts, primary care, community and specialised services -is in fact actually going up for 2014/15 in real terms.

Furthermore, under the NHS payment system, national prices are not set for mental health services. Pricing decisions for mental health services are made at local level by commissioners and providers, who are expected to have regard to the national rules but can make their own price adjustments where there are good reasons to do so.

Developing the 2015/16 national tariff

We decided to develop the 2015/16 national tariff gradually in four stages (see chart below), so we could seek input from the sector at each stage and incorporate it in the next one. This way stakeholders can see how their views are reflected as the process advances.

We decided to develop the 2015/16 national tariff gradually in 4 stages.

In the first stage, we explained the decisions we had to make in the 2015/16 national tariff in a discussion paper. The paper sought early views on some of the key issues, and called for evidence on matters that were important to stakeholders.

In the second stage, we asked for people’s views on a comprehensive list of proposed changes to the national tariff for 2015/16 and the reasons behind them, published as a set of Tariff Engagement Documents.

The next stage, currently underway, is a statutory consultation on what we propose to put into the 2015/16 national tariff in as close to final form as possible.

Monitor is required to publish these proposals as a statutory consultation notice under Section 118 of the Health and Social Care Act 2012. The 2015/16 notice, published on 26 November, includes those parts of last year’s tariff that we intend to leave as they are well as all the changes we propose for 2015/16.

This consultation includes a statutory process enabling relevant providers –foundation trusts, licensed independent providers and other providers of NHS services for which there is a national price – and clinical commissioning groups to object formally to our proposed method for calculating national prices.

If 51% or more relevant providers or 51% or more clinical commissioning groups object, we may need to refer to the Competition and Markets Authority before publishing the final national tariff (the fourth and last stage). But we hope that having engaged with providers and commissioners throughout the year and addressed their concerns where there was enough evidence, we can reach a satisfactory level of understanding and agreement. If that proves to be the case, and having considered all the other responses to the consultation, we would expect to issue the final national tariff document for 2015/16 in the New Year.

Engaging with stakeholders

Publication at each stage was preceded by targeted engagement (for example, to seek clinicians’ views on draft national prices) and followed by a wider set of opportunities for stakeholders to share their views with representatives from Monitor and NHS England.

• we held a number of workshops in Birmingham, Leeds and London. The majority covered the range of proposals for the tariff (see a summary of the discussions), but we also held a couple of workshops specifically on mental health (see a summary of one of these workshops)
• we ran 4 webinars, which discussed the proposals at varying levels of detail: watch them again
• we have also used our mailing lists, Twitter and LinkedIn to get the message out to as many people as possible

The national tariff is a technical document and the development process and final document tend to appeal to a narrow audience. So while we sought the views of patients and their representatives, much of our actual engagement was with other parties representing different perspectives on patients’ interests, in particular:

• clinical commissioning groups, who buy the care their local population requires
• providers (such as hospitals), who know how much it costs to deliver care
• clinicians and carers (and their representatives, such as the Royal Colleges), who work with patients to deliver the most effective, safe and patient-focused care

What stakeholders have said

We have received a lot of useful feedback so far. Stakeholders have told us they appreciate the efforts we have taken to make the process of setting the national tariff more transparent. But some have raised concerns about the length of documents and use of technical terminology. We are addressing these concerns by trying to make our communications more accessible and easier to understand.

Some feedback also highlighted a difficult conundrum: the national tariff needs to change quickly and fundamentally in order to enable new patterns of care, but mandating these changes without first testing them could destabilise the system. In response, we are looking to work with a selection of test sites to trial a number of innovative payment approaches that could support new models of care. Lessons from these trials will inform any wider roll-out of new payment approaches in future.

Most of the specific proposals we have made for 2015/16 over the past year have been received positively. For example, there has been widespread support for introducing a ‘best practice tariff’ that would incentivise better care for heart failure patients, and for clarifying what is required to improve the transparency of contracts for mental health services.

We have, of course, also considered stakeholders’ objections to our proposals. For example, stakeholders were largely sceptical about the benefits of using data on activities and costs from multiple years to set national prices. We took this feedback on board and have decided to stick to using data from one recent year only.

The policy that generated the most interest and debate was probably the ‘efficiency factor’. This is the percentage by which prices in the national tariff are reduced to reflect the amount providers can be expected to save by becoming more efficient while still maintaining or improving the quality of care they provide.

The efficiency factor has been set at 4% in recent years. Many providers told us that they are running out of opportunities to make further savings. They generally advocated for an efficiency factor of 3% or lower for 2015/16.

A summary of stakeholder views on the efficiency factor.

* ‘Other’ includes clinicians and suppliers of drugs and medical devices

Commissioners, on the other hand, offered a wider range of views. The majority were concerned they might not be able to afford all the care that their population would require unless prices fell materially. They sought an efficiency factor of 4% or higher. But some commissioners were more concerned by the financial implications for providers of asking them to deliver 4% efficiencies for another year. These commissioners suggested that an efficiency factor of 3 to 3.5% was more appropriate.

We have taken the range of views on board in proposing an efficiency factor of 3.8% for the 2015/16 national tariff in the statutory consultation notice.

The challenges in setting the national tariff for 2015/16

In this second blog we discuss some of the pressures that the NHS faces and how Monitor takes them into consideration when it sets the national tariff.

The NHS faces pressures from a number of sources. Costs are rising because of a combination of:

• growing numbers of patients that need care
• those patients often suffering from multiple conditions, affecting both their physical and mental health
• the cost of meeting safer staffing requirements

At the same time, while the NHS has not been subject to the spending cuts applied to other public services since the financial crisis, its budget has only been increasing in line with inflation (economists call this flat in ‘real terms’) – making the cost pressures listed above harder to meet.

Together, these conflicting pressures result in an equation that cannot balance if funding stays flat and the NHS doesn’t change.

But the NHS is trying to move the equation back towards balance in three main ways: by doing the things it does at the moment more efficiently; by doing similar things in different ways; and by doing completely different things.

As far as doing similar things in different ways is concerned, there is a lot of agreement across the NHS about what could be done differently to meet the changing needs of patients better and more efficiently. For example, making sure patients with more than one condition have all their regular hospital check-ups on the same day, instead of spreading visits for each condition over several days, could save patients time and make their life a lot easier, and at the same time cut out a lot of cost.

Doing completely different things means designing new and better ways to care for patients efficiently, or introducing really successful designs from elsewhere (See the NHS five year forward view published this week).

Helping to bridge the funding gap

Although the national tariff cannot balance the equation completely by itself, there are ways it can help the sector bridge the gap between cost pressures and a flat budget in real terms.

Firstly, the national tariff can directly press providers to manage their costs, because it determines how much they are paid for the different services they perform. For example, in recent years, prices in the national tariff have been set below the average cost providers reported for these services. This policy was intended to encourage providers to deliver care more efficiently, in line with the challenge set out by former NHS England CEO Sir David Nicholson of finding 4% savings annually between 2010 and 2015.

Secondly, the national tariff can influence not just providers but also commissioners to behave differently. That’s because prices and payment approaches in the tariff (such as “pathways” that pay for the entire course of care a patient receives) inform commissioners’ decisions about what services to commission to meet the population’s needs. They can incentivise commissioners to seek new arrangements that get patients the care they need at better value.

Thirdly, the national tariff includes rules and principles that support commissioners and providers in working together to find new ways of delivering the care that the local population needs.

A careful balance

However, the national tariff must be carefully balanced to encourage these positive trends without adding unduly to the pressures the sector faces already. Providers’ finances have been deteriorating and they may not be able to achieve recurring annual efficiencies at levels they’ve achieved in the past. At the same time, commissioners will need to divert some of their budget to the Better Care Fund next year and there is uncertainty about what benefits would be realised through the Fund. Additionally, many providers and commissioners are still figuring out how best to work with each other; Monitor needs to be very mindful of the frontline realities when setting and enforcing the rules of the national tariff.

While it might seem that a lot of this is about money, it is really about how to provide the care patients expect from the NHS in the light of the very real challenges that the service is facing. All parts of the NHS – patients, providers, commissioners, clinicians, regulators such as Monitor and others – will need to work together to make the best of what is undoubtedly a challenging situation.

Next week’s blog will describe how Monitor engaged with the various players in the sector to inform the national tariff for 2015/16 and what we heard from them.

Pricing healthcare

Welcome to the first of a series of blog posts in the run-up to the publication of Monitor and NHS England’s national tariff proposals for the 2015/16 financial year. In the series, we will set out how the tariff works. This first blog will introduce the national tariff, its aims and Monitor’s role in setting it.

Why do we have a national tariff for healthcare?

The national tariff is the mechanism by which the total amount of money the government allocates to the NHS in England is translated into health care for millions of individual patients every year.

The NHS is, of course, free at the point of delivery (the point at which patients access or use the services), but hospitals and other providers of care still need to get paid for the services they deliver. The care required by local communities is bought by Clinical Commissioning Groups who will prioritise their budgets to best meet these local needs. The national tariff is the basis on which NHS care is paid for; and it aims to be a basis that promotes the most efficient and sustainable delivery of care to patients.

The national tariff consists of:

• national prices for a set of healthcare services
• principles for how these national prices can be varied to promote innovations in service and to reflect local conditions
• rules and principles for agreeing locally how and how much to pay for healthcare services that do not have a national price

The chart below shows how the NHS budget is split across different parts of the national tariff.

*Block contracts are lump-sum payments for the provision of care. Payment under such contracts is not typically adjusted to reflect the number of patients a provider treats.

Source: Monitor, Local price setting and contracting practices for NHS services without a nationally mandated price (24 September 2013)

The power of the national tariff to benefit patients lies in the way prices and payment approaches can influence the care which is provided to patients. Prices based on accurate information on the cost and quality of services help commissioners to identify which services are best suited to their local population –  as well as helping providers to identify which activities to focus their clinical staff and resources on. Taking together all these signals that prices provide, the national tariff should inform decisions about the buying and providing of health care services that make the best use of NHS resources for the benefit of patients.

The 2012 Health and Social Care Act handed Monitor responsibility for setting the national tariff. Monitor develops the national tariff together with NHS England, with the 2014/15 national tariff (the one currently in effect) being the first we have produced jointly. We inherited the responsibility from the Department of Health (under which the system was known as ‘Payment by Results’).

We know that the current payment system does not always provide the support commissioners and providers need when making decisions on how to deliver the best for patients. We also know that the payment system cannot be reformed overnight. So, bit-by-bit we are making changes to help move towards a system that supports a sustainable future for the NHS.

In next week’s blog we will discuss some of the pressures and considerations that informed our proposals for the 2015/16 national tariff.

Getting payment for urgent and emergency care right

In Sir Bruce Keogh’s vision for urgent and emergency care, people who ask for care will be treated at or near their homes, maybe over the phone, whenever this is clinically the right thing to do. Only those in urgent need of hospital resources will go to an emergency centre for treatment.

Making this happen will improve patient care. By reducing patient pressure on hospitals, it could lower the overall costs of urgent and emergency care as well.

Connecting the dots

Realising the vision of the Urgent and Emergency Care Review depends on connecting all the services that currently provide urgent and emergency care – and their commissioners – into a single system (see image). They all need to co-ordinate their capacity planning and operations to make sure each patient is directed to the right setting and gets the right treatment on his or her first call for urgent help.

(Click on the image for a larger version)

That kind of joined-up working has been hard in the past, partly because all the players in the system get paid for what they do in different and uncoordinated ways. At the moment, reimbursement to hospitals and urgent care centres for urgent and emergency care is almost entirely activity-based, while GPs and other providers of urgent care close to home are mostly paid through block contracts. Some hospital providers could be at risk of reduced income from shifting urgent and emergency care closer to home, even if it would unclog bottlenecks or free up resources in the system overall. Hospitals do have to cover the fixed costs of having capacity ‘always on’ and are heavily dependent on activity to achieve this. Even when trying to work collectively in a wider health economy, this can act as a financial disincentive.

Focus on patient benefits

Monitor and NHS England, together with local services and commissioners putting urgent and emergency care systems in place, are working on how to align patient benefits and service providers’ financial incentives in urgent and emergency care payment arrangements. We think the way forward could be a single, consistent payment approach for every type of service in the system, made up of 3 elements:

1.    The first element would be substantial and fixed, to reflect the ‘always on’ nature of urgent and emergency care. This would help to concentrate commissioners and service providers on co-ordinating capacity planning in line with expected changes in patient flows.

2.    The second element would be volume-based and variable, to limit the impact of unpredictable fluctuations in demand on individual providers across the system. This element would also help to allocate volume and cost risk to support the kind of co-ordinated behaviours that will realise the vision of the Urgent and Emergency Care Review.

3.    Each of these 2 elements could be available at different levels or rates of payment. So the third element of the approach would be to measure the quality of individual providers and of the system as a whole and use these quality measures to determine a provider’s eligibility for their particular level and rate of payment. These measures could also be the basis for bonuses and penalties.

An urgent and emergency care payment approach with these features would allow individual providers to see some financial benefit from any steps they take that help realise this vision but which are not in their immediate individual financial interest. For instance, ambulance services could be rewarded for providing more care on scene with support from hospital consultants, reducing the need for hospital treatment; hospitals could receive a share of the system gain from this measure as a quid pro quo for providing access to the experts.

We need your input

We’re a long way off a detailed proposal for a single, consistent approach to urgent and emergency care payment across the system. The concept raises a lot of questions. How can quality and financial costs and benefits across the system be counted? Who should keep the account and manage the payment flows? How could the new approach be implemented?

We’re keen to know what providers and commissioners think of the concept, and of the many questions it raises. If you and your organisation would like to get involved, please write to pricing@monitor.gov.uk or england.paymentsystem@nhs.net. A great start would be to answer the consultation questions in our document detailing the concept by 9 September.

Getting payment for urgent and emergency care right is crucial to making the vision a reality.

Jyrki Kolsi is pricing development lead at Monitor.