What makes a good payment system?

Most payment systems need to balance competing objectives. First and foremost, the system for distributing money to care providers needs to ensure hospitals are reimbursed at a rate that reflects the unavoidable cost of delivering high-quality care and allows them to meet the needs of patients.

But the payment system also needs to incentivise wider objectives. There are financial goals – to maximise the efficiency of care and in a taxpayer-funded system, deliver financial control. The payment system needs to play its part in ensuring providers and commissioners do not overspend and are financially viable over the longer term. The payment system may also need to support wider system goals such as to reduce health inequalities, prioritise some areas of care (eg prevention) or to spur innovation.

The dimensions of efficiency

Many of these multiple objectives can be captured through various ways of looking at efficiency. Efficiency has several dimensions, all of which are important in the NHS:

  • Technical efficiency – all else being equal, services are delivered at the lowest cost, for example by treating patients as day cases rather than admitting them overnight where evidence shows that clinical outcomes are the same.
  • Allocative efficiency – resources flow to the most beneficial mix of services, for example through a better mix of prevention compared with treatment for the complications of diabetes.
  • Dynamic efficiency – over time innovations can be introduced that improve the quality of care, lower its cost or both, for example the introduction of home monitoring technology to support people with long-term conditions.

Balancing multiple objectives

Efficiency and financial control are not the only considerations. Other important objectives include delivering high-quality care, reducing inequalities and improving health outcomes. In addition to these national goals there may be other local objectives, such as supporting local economic development, reflecting the NHS’s role as an ‘anchor institution’.

In 2017, Health Foundation research found that the NHS payment system lacked a clear overarching purpose, with NHS providers perceiving the existing system to have a multitude of objectives. This is supported by international comparative research that identified 12 policy objectives for the current NHS payment system, in contrast with the three to five objectives pursued in other comparable European health systems.

Multiple objectives give rise to the potential for tension and conflict. Different approaches to payment, such as block, capitation or episodic activity-based payments, are each better suited to achieving some objectives than others. Most research suggests that for health care the optimal approach to payment is likely to involve a mix of approaches.

But balancing these different objectives through a mix of payment approaches can result in complexity. And with complexity comes the risk that payment incentives are opaque and not understood well enough to influence the behaviour of those receiving the payment in the intended way. For example, the number of tariffs (many thousands) that eventually emerged under PbR reduced their influence on hospital decisions because hospital managers and clinicians found it difficult to keep track of the likely consequences of changes to treatment.

Complexity can be minimised by clarifying who is able to influence particular decisions. Financial risks created by the payment system should only be placed on institutions able to influence those risks. And the outcomes for which an institution is being rewarded (or sanctioned) must be, to a significant extent, under their control. For example, where a provider is rewarded for treating cancer but not the initial diagnosis, it is being held to account for the speed and effectiveness of its treatment but not for the severity of the cases being referred from primary care. If there is a view that the provider itself should be responsible for working with GPs to identify cases earlier on, then a different structure of payment is needed to reflect the ability of the provider to manage risk linked to treatment and to diagnosis.

Principles for the future payment system

Previous Health Foundation research identified eight principles for future NHS payment systems (see Figure 3). These principles should inform the next steps in the design of the new approach to payments after the pandemic. COVID-19 will have an impact on NHS priorities but the principles outlined here are even more relevant to the payment system that needs to be put in place after the pandemic as they were before.

Figure 3: Eight principles for the future NHS payment system

Source: Wright et al. Towards an effective NHS payment system: eight principles. The Health Foundation; 2017 (https://www.health.org.uk/publications/towards-an-effective-nhs-payment-system-eight-principles).

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