As an Australian junior doctor doing the rounds on an otherwise unremarkable Monday, here is a list of conditions you might encounter on a typical hospital ward: lung disease, heart disease, diabetes, vascular disease, dementia…and so the list goes on. And don’t forget Mr Smith in Bed 2A – he needs a psychiatry referral, because his depression has got really bad and he wasn’t linked in to mental health services when he had a heart attack last year. Many of these hospitalisations could be prevented if patients had greater access to lifestyle management (exercise, dietary counselling, cooking groups) and community mental health support.
Primary care providers such as General Practitioners (GPs) and community nurses do a fabulous job counselling, co-ordinating care and referring to key services. But the reality is that access to community services can have long waiting lists, be limited in their coverage and prohibitively expensive. A new strategy is needed – one which:
- Improves lifestyles for patients with chronic diseases to prevent them reaching the hospital stage; and,
- Promotes patient wellbeing while also minimising healthcare costs.
Is there another way?
Enter social impact financing.
It’s a well-known fact that even within ostensibly well-financed universal health care systems, there are areas of poor service provision – particularly chronic disease prevention, or mental health services. Sometimes, charities and civil society pop up to fill the role, but this tends to result in an ad hoc patchwork of inadequately resourced services. A few years ago, policy leaders began asking, what if governments could leverage the experience and local knowledge of community groups to provide these valuable social services? And what if this could also help contain costs for government?
In 2015, the first social impact bond in healthcare was announced in the United Kingdom. Bridges Ventures, through a social impact bond funded by the Big Lottery Fund and The Social Outcomes Fund of the UK Cabinet Office, established the ‘Ways to Wellness’ program. ‘Ways to Wellness’ takes referrals from primary care providers, and provides patients with a lifestyle program to improve the management of conditions including mental illness and chronic diseases. It’s an innovative idea – chronic diseases are a significant burden on the NHS, and any steps to reduce the risk are welcome. In this model, different community service providers are brought together through a unified referral pathway, with funding attached that is conditional on achieving certain outcomes. Another example of a social investment project in health is the ‘Big White Wall’ digital mental health service, which provides accessible support to people struggling with mental illness. The social impact model is utilised in other healthcare contexts – in March, South Africa became the first middle income nation to utilise a social impact bond to fund services in maternal and childhood outcomes.
As with all pay-for-performance models, there are criticisms of the approach. Appropriate outcome measures can be difficult to design, and there is a danger that providers will only focus on measurable outcomes, to the neglect of unquantifiable but valuable results. Perhaps, more concerningly, there is a paucity of empiric evidence to support the use of social impact bonds. This is a domain that necessitates further evaluation – particularly in health and social care, where quality and accountability are imperative to patient safety. On a values basis, it can feel counter-intuitive for governments to fund charity and private groups to provide core public services, rather than investing in them itself.
These limitations merit consideration, but there also large potential advantages. By harnessing the energy and experience of established community groups with local knowledge and a professed commitment to creating change, governments may be able to bring together public services and civil society in a powerful new way. This ‘bringing together’ is what I believe to be crucial. The ‘Ways to Wellness’ model is promising because it links GPs and community nurses with a range of community services through a single pathway. It enables a package of care to be tailored for the individual, rather than ‘siloing’ people into programs with single, unconnected aims and target outcomes. Used responsibly and with rigorous evaluation, social impact financing may offer improved services to people to improve their lives.
The ground is just beginning to be broken for social impact financing and healthcare. I’m excited to see what lies beneath.
Alyssa Fitzpatrick is studying for an MPP at BSG and is particularly interested in the area of health services reform and delivery.
The Challenges of Government Conference 2016 will take place at the Blavatnik School of Government on 19-20 May. The panel discussion on “Unleashing new forces for good: Increasing social impact?” will take place on Friday, 20 May at 10:15 (UK time) and will be livestreamed on YouTube.