It’s easy to agree that prevention is better than cure when it comes to bettering the health of the population. Leading health organisations have recently published literature encouraging health services to increase their focus on prevention, with a view to saving money and reducing other costs to the economy.
But is a focus on prevention at odds with the current trend in commissioning?
The push for outcomes-based commissioning could be discounting new, innovative and particularly digital ways to address the increasing demands on health and social care. As a tool, its complexity presents many difficulties which, in themselves, are a whole other discussion. Put simply, outcomes-based commissioning refers to the impact or results that a service has on a person’s life. Measuring or proving ‘prevention’ as an impact is where providing data gets tricky.
How can an intervention show that it prevented or delayed the onset or deterioration of a long-term condition?
Let’s first think about it at a microlevel. For example, how do we prove that a service or intervention delayed the onset of diabetes in a particular person or group of people? Or that it stopped them from needing a more expensive type of medication? To prove an outcome, we would need to know what would have happened if they hadn’t otherwise used the service. Statistics can indicate what is likely to happen to a person with particular physical characteristics and lifestyle habits, but they aren’t definitive enough for commissioning purposes. How can providers show what a person would have cost health services and therefore the monetary value of prevention to commissioners? For ‘prevention’ to show a positive result, assumptions about what would have happened need to be made. This goes against the very ethos of outcomes-based commissioning.
At a macrolevel, studies and trials can compare the health outcomes of one group with another. Has the health of the group using this service deteriorated as badly or quickly as the group who haven’t? How does their number of emergency admissions compare? Are they healthier? Typically these studies require large numbers of participants over long periods of time to evidence trends, and this is especially true of long-term conditions. If the burden is on service providers to supply this evidence to satisfy the requirements of outcomes-based commissioning, small and medium enterprises are at an immediate disadvantage in the healthcare market. It could also delay services being made available to the general public. History is peppered with examples of innovation, such as the discovery of penicillin, which have been developed but only taken to scale many years later with a large amount of outside investment.
Limited competition and options fosters poor value-for-money- the opposite of what outcomes-based commissioning is supposed to achieve.
Innovative products which break into new areas and forge new roads, are often untested on a large scale and can struggle to develop and attract investment. This makes it easier for large, multinational companies with deep pockets to dominate the world of digital healthcare and influence what outcomes commissioners look for, perpetuating an uncompetitive marketplace. This will cost the public purse more in the long run as well as limiting the types of products and services available.
It doesn’t reflect rapid changes in the digital world.
Any digital platform is likely to look and interact differently with users just a year or two on from its initial launch. By the time a study makes a conclusion on the effectiveness of a platform, it will probably have changed significantly to keep up with user behaviour and expectations. Because the impact of a digital platform is intricately tied into the user experience, studies on effectiveness could be rendered obsolete when the user experience changes.
The requirement for outcomes may be stopping prevention services from flourishing and implementing services which could see greater savings in health and social care spending. The ageing population and our collective lifestyle point towards rapidly coming crises in health and social care as well as long-term conditions making up the bulk of NHS spending. Inevitably, commissioners are turning to digital technologies to get the scalability and value-for-money they are seeking. Which begs the question of whether commissioners really have the time to wait for outcomes of studies and clinical trials on new innovations.