Week 10: Commissioning for Quality & Outcomes

The next @WeCommissioners live Tweet Chat at 8pm on 6 May is on the subject of Commissioning for Quality & Outcomes.  This is the current version of the pre-chat blog.

First a quick recap on commissioning: “Commissioning in the NHS entails decisions about needs assessment, resource allocation, service purchasing, monitoring and review.” Nuffield Trust, 2014.

Secondly, what is meant by quality and outcomes: In the NHS Next Stage Review, 2008, quality is defined by Lord Darzi as care which is "clinically effective, personal and safe".  Outcomes are the results of support activity or interventions for the person, not the activity itself; these can be measured or defined in a range of ways, including Patient Reported Outcome Measures (PROMS).  This specifically means outcomes for people in terms of how their health and wellbeing is safeguarded, improved or how they are affected by a specific procedure, course of treatment or other intervention.

The Commissioning Cycle has a number of stages where quality and outcomes are important to incorporate:

Historically, NHS services have been paid for through agreements and contracts based on the quantity of what is provided; more recently, the introduction of quality into these agreements has seen improvements and now there is a greater move towards payment based on outcome rather than quantity of service provided.  Yorkshire & The Humber Joint Improvement Partnership has some useful information and resources on outcome-based commissioning aimed at commissioners of adult health, wellbeing and social care services.  The approach to commissioning for outcomes is not exclusive to healthcare and commissioners of social care services are also moving further in this direction.  A seminar in January 2014 ‘Commissioning For Better Outcomes’ by the President of the Association of Directors of Adult Social Services (ADASS) describes how this works in this area.

The National Institute for Health & Care Excellence have produced a national Clinical Commissioning Group Outcome Indicator Set.  These are intended to “support CCGs and health and wellbeing partners to plan for health improvement by providing information for measuring and benchmarking outcomes of services commissioned by CCGs”

There are a number of tools at different stages of the commissioning cycle that are used to ensure a quality and outcomes focus to commissioning, specifically through the annual commissioning elements relating to contracting.  Requirements for quality and outcomes are specified to commissioners through the Standard NHS contract.  Once commissioners have identified the quality standards and outcomes that are to be achieved by a provider, it is through the contract that these are formally agreed.  Following this, there should be a robust and planned process for regular monitoring of performance against these standards to ensure they are being met.  For some standards where they are met, providers can receive additional payments from commissioners and for some where they are not met, commissioners can impost financial penalties.  These details are all specified within contracts.

Further Resources:

NHS England 2014/15 Commissioning for Quality & Innovation Guidance

NHS Library Service Commissioning Handbook for Librarians

NHS Confederation Briefing ‘Two sides of the same coin: Balancing quality and finance to deliver greater’

ADASS –Association of Directors of Adult of Social Services

Public Health Outcomes Framework 2013 - 2016

Social Return on Investment Network Intl

Outcomes Focussed Services for Older People, Social Care Institute for Excellence

Week 9: Continuing Healthcare

One of the central principles of the new NHS in 1948 was to be free at the point of need.  Aside from some notable exceptions such as prescription & dental charges, this continues to be the case in the NHS in England.  This principle has been questioned and challenged over the years; more recently by a suggestion that people could be charged a monthly ‘subscription’ fee.  Fortunately, so far, this isn’t formal Government, opposition or NHS policy.

Although NHS services are free to all at the point of need; who ‘qualifies’ as being in need doesn’t always equate to everyone, all the time.  There are many issues of geographical difference of services, often referred to as the ‘post-code lottery.  I may write a blog on that subject in the future, but this one is focussed on another element, namely continuing healthcare. This is when it is established that a person has complex and ongoing healthcare needs that should be met outside of hospital. People are assessed as to whether they qualify for NHS for this.  This assessment of need is done through a formal process; initially using a screening tool called a Checklist, which is used to identify whether a person requires a more in-depth assessment.  If so, then a multidisciplinary assessment is undertaken supported by a Decision Support Tool.

If a person, following assessment through the Decision Support Tool is identified as meeting the criteria for NHS funding, a ‘package’ of care is then commissioned to ensure that these assessed needs are met on a continuing basis.  The assessment is multidisciplinary, including health and social care staff.  There are e-learning tools available, aimed at both NHS and Local Authority staff involved in the process.  Each stage of the process is open for appeal and if someone has a more urgent need to get service in place quickly, i.e. for someone near end of life, there is a Fast Track process to ensure this happens without delay.

I attended an NHS England Roadshow this week for CCG Directors of Quality & Nursing and people from the NHS & Local Authorities responsible for commissioning Continuing Healthcare.  The focus of the event was a new Quality Assurance Framework, which is yet to be formally published.  The framework is intended to assess both the quality of the assessment process and the quality of service received through a series of prompts.  This is intended to form part of and not to replace local quality assurance systems.  The prompts have two distinct features:

1.      Firstly, they are set out as a series of statements starting “I...”, as quality should be assessed from the perspective of the person receiving the assessment and the continuing healthcare itself; or their family/carer(s).  For example: “I felt the assessment focused on me as an individual and helped me live the best life I can” and “I am supported to have choice and control wherever possible over my care and support”.
2.      Secondly, the framework is built around the ‘Six Cs’, i.e. the prompts are separated into six category headings: Competence, Courage, Commitment, Care, Compassion, Communication.

As a group of Directors of Quality & Nursing from our local area (Hertfordshire & South Midlands), we agreed at the Roadshow that we needed to do more work locally to ensure that we consistently embed this assurance framework into our quality assurance systems.  We committed to doing this collectively.

Finally, but very significantly, since 1 April 2014, all recipients of continuing healthcare are entitled to request a Personal Health Budget(PHB).  This allows individuals to directly ‘commission’ their own NHS-funded package of care, personally selecting the agencies and sometimes individuals who will meet their needs.  NHS England’s vision for personal health budgets is “to enable people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive”.  PHBs were originally piloted and have been evaluated.  The website for the evaluation project and the final report contain a lot of detail on what was found.  In summary, the pilots showed that people had: more control, greater choice, better care-related quality of live and significantly lower cost.

Week 8: “It’s the economy, stupid”

NHS Clinical Commissioning Groups (CCGs) are the part of the NHS responsible for commissioning health services for a local population.  In simple terms, this means assessing need, purchasing services and ensuring NHS funded service providers achieve required quality & outcomes.  Some health services like primary care (GPs, Dentists, Pharmacists & Optometrists) and specialised services, such as renal (kidney) dialysis services as well as neonatal care, severe burns care and some mental health and children’s services are commissioned by NHS England while public health services are commissioned by local authorities and Public Health England.  One key function of CCGs and all commissioning organisations is to make the best use of the resources available to them, i.e. spend NHS (public) money wisely on behalf of the population they serve.

This week CCGs were one year-old on 1 April 2014 following the NHS reforms in England.  The Kings Fund and The Nuffield Trust marked the occasion by writing 'How engaged are CCG members one year on?’ and ‘Clinical commissioning groups – one year on’ respectively.  Where I work in Luton we have had productive year developing the CCG into an organisation more focussed on the needs of the people of Luton who we’re here to serve; building on the fantastic work done whilst in ‘shadow’ form the year before (that’s a lot less sinister in reality than it sounds!).

One challenge we started the year with that remains with us is the constraints of the financial resources we have available to us.  This second year for Luton CCG will be equally financially challenging. I know that’s an oft heard refrain in the NHS and the wider economy, but let me explain a bit more about why this is a specific challenge in Luton.  In Luton, the services paid for by the CCG, in the financial year that ended on 31 March 2014, have cost more money than we received from Government and therefore ended the year with a deficit.  The exact size of this deficit is yet to be determined, as we’re still ‘closing the accounts’, i.e. doing all the final sums to identify exactly how much more have we spent than we had coming in.  At our Public Board meeting in February 2014, the forecast deficit was predicted to be £5.3M.  This is not the first year this has happened in Luton and based on the current accepted formula Luton receives about 7% less money annually than it should compared to other areas of England (NB CCGs receive our funding from Government, i.e. publicly funded through taxation).

There will be a modest increase in funding for health services in Luton commissioned by the CCG over the next two years, but this will only partially close this funding gap.  By 31 March 2016 (two year’s time) we are expected have to not only ensure that what we spend matches what we receive, but we’re required to make a 1% surplus each year (end the year with having spent less than 99% of what we receive from Government) for investment into new services.  Unlike in previous times in the NHS, there will be no bail-out from the powers above us and whilst we have locally secured ‘brokerage’ (a short-term loan from other nearby commissioning organisations) we have to not only pay this back in the next year, but we also to reduce the amount we spend more than we’re allocated.  This doesn’t equate to cutting services, but to being more innovative and efficient about how we use the money we do have, including through an approach called QIPP (Quality, Innovation, Prevention & Productivity).

This is a significant challenge and there is a great deal more complexity in this than is summarised in this blog but we’re up for the challenge.  We fully intend on meeting the tough standards we’re required to achieve and those we’ve set for ourselves.  Our plans for the coming year, and beyond, will ensure we work with local people and clinicians to be more focussed on the needs of the rich diversity within Luton to improve their health and outcomes.

(PS this blog is not intended to be a master class in NHS finances – if you want to read more about NHS finances, the NHS Confederation has some helpful resources.)