HEALTH CARE AND POPULATION HEALTH
There is often confusion in the public mind between health care, health and hospitals. Whilst hospitals are the public face of the healthcare system the majority of health is generated elsewhere. The wider determinants of health include housing, employment, education and wider societal factors. At its most extreme some healthcare groups such as Kaiser Permanente regard hospital admission as a failure of the system. Is it is against this backdrop that the next steps should consider the role of wider health care goals and non-hospital-based activity in relation to ABF/A BM. There is a danger that activity based costing systems incentivise hospital activity as the literature reviews above demonstrate. However this does not have to be the case. A strong
drive from a purchasing function can ensure that resources are shifted to out of hospital care. This will need a clear direction in terms of performance management and “tuning” the payment mechanism. Area health services are well placed to deliver the more high-tech and clinically advanced hospital at home initiatives. Consideration should be given to a wider variety of community and third sector providers for the more community and social end of care. As result of changes to payments beyond high boundary levels funds will become available in the system. It is suggested that these funds are directed towards out of hospital
care to prevent admissions, particularly around chronic care conditions. There exists an opportunity to work with the embryonic Medicare locals to ensure the success of such initiatives. The question was raised whether activity based costing methods could be applied across all health services. In particular public health activities were deemed to be a challenge for this methodology. However it is possible to use a tariff-based system for public health and health promotion. For the last year in the West Midlands of the English NHS a tariff-based system has been used for smoking cessation. Providers are rewarded according to 4 week or 12 week quitters. More importantly the tariff is varied such that it rewards providers for working with target groups. This includes people from ethnic minorities, those from deprived communities, people with disabilities and women smoking during pregnancy. The 25
unit cost for work with his target groups can be more than double that for the average member of the population.