Balance between complexity of design and ease of use

 

A consistent theme in the research was the highly complex nature of payment systems. In part, this reflects the complicated task of delivering health care, so a degree of complexity may be unavoidable. But care should be taken to ensure that the level of complexity is proportionate to the primary purpose of the payment system.

Increasing layers of complexity

Piecemeal evolution of the current system has meant that new rules or mechanisms are put in place to address specific concerns, without full assessment of their impact. More could be done to test whether the resulting complexity creates bigger challenges than the ones it was intended to fix.

PbR has got more and more complicated and we increased the number of health care resource groups. NHS contract manager

Clarity of purpose for the system (see principle 1) can help determine whether or not to implement a change. A principle that requires payment to influence behaviour will require a more complex system than one that purely facilitates financial transactions. Any added complexity should directly support, or at least not conflict with, the primary purpose of the system.

Support for operating in a complex system

Where complexity is necessary, adequate national support should be provided to reduce the impact on those operating systems at local and regional levels. For example, making the software code for applying payment rules publicly available would allow it to be applied and adjusted as appropriate. This would avoid duplication of effort across providers and commissioners, as well as researchers, while improving consistency and accuracy.

The terminology and mechanisms associated with payment systems can be burdensome and even incomprehensible.

Sometimes we just take for granted that most people understand this, and you’d be surprised how many people still are not savvy on finance structures. NHS medical director

This is a barrier to engaging staff on payment issues, especially clinicians, whose engagement is important for the success of payment incentives. It may also prevent providers from mounting an effective challenge when faced with difficulties in payment systems.

There is a lack of knowledge [of PbR within the trust]… I think that lack of knowledge… creates confusion. NHS contract manager

It can also create challenges when making service changes that require flexibility in the payment system.

Even agreeing relatively modest service changes in the current environment, where you have to agree a [new] price, is incredibly resource-intensive. The best example we’ve got is a fracture clinic, which has been going on for years. It’s a way of providing a service so [patients] come in as outpatients… it should be easy [to set up], but because we’ve overlaid everything [with tariff rules and prices] we have this huge complexity… No one feels empowered enough to just say, ‘This is actually a big improvement for patients.’ Yes, we need to collaborate [with commissioners] on how we deliver the service and the pathway, and this is how it will work, but how long has this been going on? NHS contract manager

Some level of complexity may be unavoidable given the nature of the NHS. But care should be taken to ensure that the level is appropriate to meeting the primary objective, avoiding excessive complexity in order to meet competing secondary objectives. Furthermore, adequate support must be provided to staff implementing complex systems.

System designers should view complexity as a design challenge, while ensuring that execution remains manageable – just as a car is complex in design, but relatively simple to operate with basic training. The current payment system provides the components and instructions – but not a consistently functional and effective product.

Conclusion

Many participants were uncertain about the level and breadth of understanding of the payment system(s) within their organisation, particularly outside finance and contracting departments. Evidence suggests that new payment systems, and PbR in particular, require technical skills to understand and negotiate. This can create extra work and requires a higher level of expertise, which may consequently add to costs. When designing a new system, policymakers must consider the resource burden of implementation.

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