2015 Spending Review

Fresh from the 2015 campaign trail, Chancellor George Osborne announced in the November 2015 Spending Review, that funding for the National Health Service (NHS) would increase from £116.4 to £133.1 billion in the 2016-17 fiscal year; a real terms increase of £4.5 billion. On current projections, over the two terms of the current Government, spending on the NHS in England on will have risen by nearly £35 billion, an increase of 35%.

Around £24 billion of this amount will, however, be absorbed by inflation leaving a real terms increase of just £11 billion (or 0.9% per year over eleven years) 1. Increasing life expectancy, an aging population, diminishing opportunities for productivity gains and an unfriendly fiscal future will make even this increase seem insufficient to meet organisational needs. The rise of long-term conditions (LTC) is set to pose a particularly formidable challenge to western medical systems over the next 50 years, including the NHS.

Over 15 million people in England have a LTC, and they utilise a significant percentage of NHS services and resources (50% of all G.P. appointments, 70% of all hospital bed days and 70% of the total health spend) 2. Through the change programmes, the NHS can test new solutions and calibrate its response to the challenge of LTCs. PAM, or the "Patient Activation Measure" is one such solution. The Patient Activation Measure is intended to equip LTC patients with the knowledge, skills and confidence with which they can take responsibility for, and manage their healthcare, improving overall outcomes and reducing budgetary pressure.

What (and not who) is PAM?

The Patient Activation Measure (PAM) is a commercially licenced tool, which enables healthcare professionals to ascertain a patient's "level of activation" (a patient's level of skill and knowledge for dealing with their own health care). With this information, healthcare professionals and Clinical Commissioning Groups (CCGs) can tailor care provision to the patient's, and the wider community's needs. It is estimated that between 24 and 40% of the UK population have low levels of activation.

PAM licences are issued on a per patient basis, and are purchased from the licensee of the product. Each licence covers a single patient for the duration of the licence agreement, and during this time the healthcare professional will work with the patient in order to improve his / her ability to manage their own long-term care (known as increasing the patient's "level of activation"). Think tank The Kings Fund has analysed the effectiveness of the PAM model, and has found that targeted interventions can increase a patient's activation score; significant improvements have been seen in patients who were, at one time, the least activated, and evidence shows that patients with higher levels of activation tend to experience "better health, have better health outcomes and fewer episodes of emergency care, and engage in healthier behaviours" 3.

The process of improving the patient's ability to manage their own long term healthcare begins with a questionnaire. On the basis of their answers, patients receive a PAM score between 0 and 100, which is used to classify them according to the activation scale. There are four classifications on the activation scale, depending on the patient's PAM score: a level one patient is a patient who is "disengaged and overwhelmed", lacks confidence and displays little knowledge of how to manage their long term care; a level two patient is a patient who is "becoming aware, but still struggling", and while able to set simple healthcare goals, will lack the overall ability to manage their long term care; a level three patient is a patient who is "taking action", and building key self-management skills; and, at level four, the patient is "maintaining behaviours and pushing further", maintaining a healthy lifestyle and advocating on their own behalf 4.

With the information obtained from this process, healthcare professionals can tailor care provision to the individual patient, and work with them in order to help them develop the skills, knowledge and confidence to manage their health in the long-term and keep well at home. This approach is intended to improve patient outcomes, enable the patient to advocate on their own behalf, and reduce the overall long term costs of treating LTCs. At the macro level, CCGs can aggregate the information obtained from PAM patients in their area, and use the data to measure the effectiveness of healthcare services, evaluate commissioned programmes, and guide future procurement processes.

PAM and the NHS

A recent study found that patients with low levels of activation had 8% higher costs in the base year of the study, and 21% higher costs in the following year, as against patients with higher levels of activation 5. The NHS, facing £22 billion of savings as part of the efficiency challenge, has a direct interest in investigating the most cost effective way of providing high quality healthcare.

It was, perhaps, with this imperative in mind, that NHS England launched a PAM pilot, involving five CCGs, the UK Renal Registry and 100,000 patients. The pilot was sufficiently successful, that in April this year, as part of its "Self-Care programme" (established to improve support for patients with LTCs) NHS England agreed a five-year licence agreement with Insignia LLC, which will expand access to PAMs to up to 1.8 million patients 5.

Forty CCGs, local authorities and third sector primary care providers along with key NHS change programmes (New Care Model Vanguards, Integrated Personal Commissioning demonstrator sites and Integration Pioneers) were invited to apply for PAM licences, with midday on 17 May 2016 deadline for applications. Training workshops for successful applicants will be held throughout June.

With the up scaling of the PAM, programme participants will feed back additional data on levels of patient activation, and the impact of the programme on resource allocation. Evidence has shown that, from an organisational standpoint, the impact of the PAM is best measured through larger scale roll-outs. Whether PAMs represent the future shape of care provision for patients with LTC, we will monitor the success of this phase of the programme with interest.

For further information, please contact Jane Bennett, Associate or Sean Goldstein, Trainee (sean.goldstein@bevanbrittan.com).


  1. http://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget
  2. https://www.england.nhs.uk/wp-content/uploads/2013/07/nhs_belongs.pdf
  3. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf
  4. http://www.insigniahealth.com/products/pam-survey#
  5. https://www.england.nhs.uk/2016/04/person-centred-support/
  6. https://www.england.nhs.uk/wp-content/uploads/2016/04/pa-interim-report-summary.pdf

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