What should good commissioning involve?
There are a number of different ways of defining good commissioning. The Department of Health commissioning framework (July 2006) best describes a multi-faced commissioning cycle (see diagram below).
Commissioning is an ongoing cycle of processes which have to be undertaken to demonstrate compliance with procurement rules. The fundamental elements of commissioning have not changed through the White Paper. The responsibility for identifying local health priorities for services is the role of clinical commissioning groups (CCG‘s) and the NHS Commissioning Board for specialist service.
CCGs are expected to initiate and maintain dialogue with a variety of groups to ensure that commissioning decisions are not made in isolation either from the patients and public, local authorities or other health and care professionals. Successful commissioning can only be achieved with GPs, secondary and tertiary care clinicians (senior hospital doctors, medical academic and public health medicine doctors) working together.
Commissioners need to take account of a wide range of factors to make informed decisions. These include national guidance and priorities, clinical evidence, ethical frameworks, local needs, access to services, service quality and outcomes.
The three main areas of commissioning and the required activities are discussed below under Planning, Procuring and Monitoring.
A. Health Needs Assessment
Commissioning decisions must be underpinned by a robust assessment of needs across the local health community. For seamless care to happen care pathways need to be designed to meet local need and individual need.
It is essential that a review of primary care, intermediate and secondary care activity is undertaken to identify skin disease rates. Secondary care activity must be reviewed by commissioners in conjunction with local dermatology clinicians. This is essential as dermatology departments may only record new: follow up activity due to block contracts or will only record outpatient procedures. Unfortunately this does provide accurate information for commissioners on skin disease rates or the complexity of care of service users.
Local GPs may be able to assist if they regularly enter the diagnosis provided on the patient’s letter into the patients record. However, this will not capture any co-morbidities etc unless onward care is needed.
Identifying unmet need is also essential as this overflows community service and increases referrals to secondary care. Demographic profiles are needed to look at local areas of deprivation which include health morbidities such as diabetes, obesity, alcoholics and smokers. Ethnic groups also have different prevalence rates and types of skin disease.
B. Reviewing Current Provision
Any proposed service redesign must follow the principles of commissioning for planning which includes a needs assessment, cost analysis of care pathways and extensive consultation with public, patients and clinicians over the care pathways themselves. While this can be a time consuming and costly exercise undertaking this mandated process, the cost of getting it wrong causes destabilization of services and is an even greater burden to the taxpayer.
Many community services have failed time and time again due to poor commissioning. The benefits and saving for providing community services must be realized before any service is redesigned. Quality must be the focus in order to drive down cost.
Current services (including primary care) require regular review to ensure they are adequate, appropriate and of sufficiently high standard to meet the needs identified in the Health Needs Assessment. Performance management of providers based on accurate data and information is an increasingly important element of the consideration of current service provision. Patient and population feedback and choice are also important elements to consider.
C. Identifying Gaps and Priorities
Services need to be examined to identify gaps in overall provision, quality, cost effectiveness and geographical distribution. National and local priorities need to be taken into account, when deciding on which services to commission or possibly decommissioned, for reasons such as duplication or they do not add value.
D. Capacity Planning
It is vital that planned services have sufficient capacity to cope with fluctuations in demand, avoid duplication and ensure delivery of quality. Ongoing planning and monitoring are required.
Any change to a service must be discussed in advance with the local Health Overview Scrutiny Committee (Public Scrutiny Panels). The reasons for service change must be based on identified needs and evidence based practice to deliver cost-effective services. These changes will result in a community service specification or an acute service specification being created for the contract.
B. Defining Contracts
This stage converts the service specification into a written contract that takes into account activity and quality requirements.
C. Procuring Appropriate Services
This could be re-contracting for existing services (renegotiation of contracts where appropriate) or procurement of new contracts. New contracts can be procured through a number of routes, for example ‘any willing provider’ mechanisms or national tendering. Quality stipulations will need to be considered such as through the Commissioning for Quality and Innovation (CQUIN) payment framework, which sets out a commitment to make a proportion of the provider’s income conditional on quality and innovation. The indications within the new NHS Outcomes Framework will also be a key consideration here.
D. Managing Demand
This could be re-contracting for existing services (renegotiation of contracts where appropriate) or procurement of new contracts. New contracts can be procured through a number of routes, for example ‘any willing provider’ mechanisms or national tendering. Quality stipulations will need to be considered such as through the Commissioning for Quality and Innovation (CQUIN) payment framework, which sets out a commitment to make a proportion of the provider’s income conditional on quality and innovation. The indications within the new NHS Outcomes Framework will also be a key consideration here. Services require checks and balances to ensure they are not overused (resulting in extra costs being incurred) through unmet need or underused (resulting in wasted resources). Managing demand also requires commissioners to assess changes across the care pathways being delivered. Moving intermediate care into the community results in more complex cases being undertaken by secondary care. This has an impact on the cost and time taken to treat the patient and may affect capacity and costs which will need to be monitored as part of existing contracts.
A. Managing Performance
Robust monitoring of activity and budgets is required for all providers of dermatology services. Commissioners require timely information on the volume of services utilised by them, the quality of the services and what resource is being committed through new referrals and therefore what their likely budget outturn will be. They may then need to review providers to ensure that appropriate activity is undertaken to ensure they do not overspend. Through such monitoring, they will know whether a provider is delivering according to its contract and to an acceptable level of agreed quality.
Contract challenges may be necessary, if information cannot be validated, or if a provider unilaterally increases or decreases activity thresholds outside agreed tolerances or if quality is questioned, for example, through CQUIN.
B. Patient Choice
Putting patients first means that they receive high quality and up to date information on services to assist them in making real and informed choices. The Local Authority and the Health and Wellbeing Boards (or similar) will require information on services, particularly from their local HealthWatch.
C. Public and patient engagement requirements
Engagement with patients and public requires an ongoing, two-way dialogue. Feedback must be incorporated within every stage of the commissioning cycle; it is not a stand alone process. GP Commissioners will need to build on their established engagement mechanisms to ensure that the patient voice impacts on their commissioning decisions. This is a requirement under the NHS Health Act and NHS Constitution.