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MAY/JUNE 2012
OFF TO MARKET With reforms underway, is the NHS
turning into a marketplace?
CUTTING RED TAPE How to establish a clinically-led
organisation without the bureaucracy
ON WITH THE SHOW Commissioning Show 2012: a guide
Editor’s letter
Welcome to the second edition of Commissioning Success magazine. Now that we’ve got the ball rolling here at CS Towers and the Health and Social Care Bill has become an act, we want to hear from you.
How’s it going? Got any success stories? Please get in touch on [email protected] and share your experience, because once all the fanfare dies down, all that will be left are the CCGs and eventually the lion’s share of the NHS budget. Do you think you can cut it?
It seems from the commissioners I’ve met you certainly can. On page 18 I interview Wigan Borough CCG, which is making waves with COPD through a ‘Breathlessness’ campaign. They’ve taken an interesting approach to commissioning by keeping localised mini-groups within the larger commissioning organisation to ensure ‘local’ stays on the table.
On page 22 I speak to the very forward-thinking Durham Dales CCG, which is nominated for a BMJ Award for their commissioning work. They really are covering lots of bases – from diabetes to IBS and even putting beds in GP practices.
The idea of keeping local at the heart of commissioning seems to be important as CCGs prepare to take over responsibility for commissioning care from PCT clusters come April.
In his speech at the annual BMA’s GP conference, Dr Laurence Buckman, chairman of the BMA’s GPs committee warned that many GPs are feeling left out of the commissioning game. Of course, this is understandable as commissioning has truly become a day job for those involved, however, the CCGs that I’ve seen doing a great job of things have involved everyone – both directly and indirectly – whether that be through monthly CCG-wide meetings or groups that feed information to the board. It’s important that every patient voice is heard and to do that, a lot of fingers need to be in a lot of pies.
EDITOR
CONTENTS COMMISSIONING UPDATE
4 News and updates The latest news, comment and views on clinical commissioning
7 Be prepared Dr David Paynton, national clinical lead at the RCGP Centre for Commissioning readies CCGs for the year ahead
8 Commissioning Show 2012 A commissioner’s guide to the annual CCG event
12 We’re all off to market Now that GP-led commissioning is well and truly here, Roger Hymas looks at where the journey will take us
COMMISSIONING IN ACTION
18 Wigan Borough CCG Dr Tim Dalton, clinical chair, and COO Trish Anderson, take a big picture approach to commissioning pathways
22 Durham Dales CCG The dream team at Durham Dales commissioning locality is making waves with its pathfinder work
COMMUNITY CARE
28 Reduce and deliver Paul Robinson offers advice on reducing hospital admissions
30 Forget me not Working together to tackle dementia
INFORMATION AND TECHNOLOGY
32 Top tips Five ways to improve data exchange in your commissioning group
34 Telehealth How CCGs can take advantage of telehealth for better outcomes
MANAGING COMMISSIONING
36 Understanding procurement Ways that CCGs can understand and procure even better
38 Just say no Cutting back on red-tape so commissioners are left to commission
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Commissioning Success is published byIntelligent Media SolutionsSuite 223, Business Design Centre52 Upper Street, London, N1 0QHtel 020 7288 6833 fax 020 7288 6834email [email protected] www.intelligentmedia.co.ukweb www.commissioningsuccess.comPrinted in the UK by Buxton Press www.buxtonpress.co.ukC
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04 | MAY/JUNE 2012
NEWSWAVE 1 CCGS ANNOUNCEDThe NHS Commissioning Board Authority has confirmed the 35 aspiring clinical commissioning groups (CCGs) in the first wave of authorisation. These are: According to the latest research from the
Institute of Healthcare Management (IHM)
over three quarters (78%) of managers
surveyed in the healthcare sector believe
that patient care is at risk due to a lack of
proper staff training and development. Some
87% of those surveyed believe this training
gap has resulted in low team morale while a
further 87% cite a lack of confidence in staff
as a direct consequence, resulting in slipping
standards and ultimately, putting patients
at risk. The survey comes in the wake of
the King’s Fund’s report into leadership for
engagement in the NHS.
More training needed for managers
HEALTH ACT TO IMPACT DATAThe Health and Social Care Act 2012 will
have “severe implications” for collecting and
monitoring data about the health needs of the
population in England, warn experts
In a paper published on bmj.com, Professor
Allyson Pollock, Professor Alison Macfarlane
and Sylvia Godden argue that the new
legislation will make it “extremely difficult” to
monitor health inequalities and access to care
locally or nationally.
The administrative structure of the NHS
in England is currently based on resident
populations of defined geographical areas.
Under the new legislation, most health services
will transfer to non-geographically based
CCGs that will be able to recruit patients living
anywhere in England. This, warn the authors, is
likely to lead to erosion of data quality, accuracy,
and completeness.
They conclude: “The NHS is founded on the
principle of comprehensive coverage. Equitable
public health activity requires reliable information.
The abolition of area-based structures and
the transfer of most responsibilities to non-
geographically based CCGs, as well as some
responsibilities to local authorities, undermines
the availability of information and routine data
required to monitor the...health service.”
• Bassetlaw• Blackpool• Bedfordshire• Calderdale• Cumbria• Dudley• East & North Herts• East Leicestershire & Rutland• East Riding• Gloucestershire• Great Yarmouth & Waveney• Islington
Applications for authorisation will take place in four waves from July
2012 to January 2013. Meanwhile, in the second stage in the business
review process for commissioning support services (CSSs), three
services failed to make the cut.
The objective of checkpoint two is to assess whether emerging
CSSs are on are track to developing a full business plan by August
2012 when they will undertake the final checkpoint, prior to a
decision on hosting arrangements by the board authority.
Twenty-six regional NHS commissioning support services and the
nationwide NHS Communications and Engagement Service submitted
business plans for checkpoint two. Of these, 14 had “medium to low
issues”; nine “need more rapid management”; and three failed to pass.
Chronic Obstructive Pulmonary Disease
(COPD) lies at the centre of the QIPP
agenda for Newark and Sherwood Clinical
Commissioning Group. As a result, they have
embarked on an innovative approach to
improve care for patients with this condition
by joining forces, not only with the local
acute trust, community providers and
patients but also with the pharmaceutical
industry to create PANNASH – the Pulmonary
Advancement Network for Newark and
Sherwood Health, to help people with COPD
better manage their condition.
Newark takes a breath of fresh air
LOCAL NEWS
• Kernow (Cornwall)• Kingston• Leicester City• Liverpool• Newbury & District• North & West Reading• North East Lincolnshire• North Staffordshire• Oldham• Oxfordshire• Portsmouth• Rotherham
• Sandwell • West Birmingham• Shropshire• Somerset• South Reading• Stoke on Trent• Wakefield• Wandsworth• Warrington• West Cheshire• West Leicestershire• Wokingham
MAY/JUNE 2012 | 05
UPDATENEWS
SEND IN YOUR STORIESWe are always looking for local commissioning news. If you have a story to share, email [email protected].
CLINICAL CORNER
The National Audit Office has issued a report finding that, despite some improvements since 2006-07, there is poor performance against expected levels of care, low achievement of treatment standards and high numbers of avoidable deaths, and concludes that diabetes services in England are not delivering value for money.
In 2009-10, there were an estimated 3.1 million adults with diabetes in England. The number of people with the condition is expected to increase by 23% to 3.8m by 2020.
NAO CONDEMNS DIABETES CARE
Men in Sunderland were invited to stop by a
local network event in April, aimed at involving
local people in tackling men’s health issues.
Sunderland has some of the worst areas
of deprivation in the UK and although overall
life expectancy for people in Sunderland is
increasing, the gap between Sunderland and
the rest of England is not closing, especially
for men.
In the last two years life expectancy
for men has widened slightly. The latest
information suggests that average life
expectancy for men is 75 years compared to
77 years for England.
Last year the public health team at
Sunderland Teaching Primary Care Trust
(PCT) set up a Men’s Health Steering Group,
made up of a range of organisations across
the public, private, community and voluntary
sectors that focus on men’s health.
As part of this the Men’s Health Network
was launched with bi-monthly meetings to
bring men from across Sunderland together
to discuss men’s health to ensure they
themselves can contribute to the evolving
health improvement initiatives.
Sunderland Men’s Health Network reaches out to men in the local area
Yusuf Meah, promoting health practitioner
for Sunderland Teaching PCT said: “We are
encouraging men to stop by the Men’s Health
Network event which is raising awareness of
men’s health issues and encouraging men
to get involved. The network gives men the
opportunity to become aware of the current
work on men’s health in Sunderland which aims
to narrow the gap of male life expectancy.”
There are a number of health issues that
contribute to high male mortality in the North
East and specifically Sunderland, including
lung, prostate, testicular, and bowel cancer.
LOCAL NEWS
Patients with long-term conditions in South
Tyneside are able to monitor their health at
home reducing hospital admissions and visits
to their GP thanks to new a new telehealth
initiative in the area.
The telehealth team at NHS South of
NHS South of Tyne and Wear uses technology to monitor LTCs
Tyne and Wear won the partnership award
in Sunderland City Council’s Star Awards
2012 in recognition of creating a successful
partnership across South of Tyne and Wear,
to develop and promote telehealth and
assistive technologies.
Paul Marriott, project manager for
telehealth at NHS South of Tyne and Wear,
said: “Telehealth aims to improve the health
and wellbeing of those people with a long-
term condition by enabling them to manage
their condition more effectively. It also
supports earlier discharge from hospital and
supports people in their own home rather
than admitting them to residential care, and
increases patient and carer independence.”
LOCAL NEWS
20-22 JuneNHS Confederation Annual Conference
and Exhibition
Manchester Central Convention Complex
conference.nhsconfed.org
DIARY
MAY/JUNE 2012 | 07
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Be preparedWith clinically-led commissioning upon us, DR DAVID PAYNTON, national clinical lead at the RCGP Centre for Commissioning readies you for the year ahead
Clinical commissioning sets new challenges and opportunities for the NHS and primary care, being fundamentally different from primary care trust commissioning in that clinical
commissioning groups are:
• membership organisations, with the membership coming from the constituent practices as well as being a statutory bodies • commissioning for outcomes as opposed to PCT contracting for activity • accountable to local authorities via the health and wellbeing boards as well as the National Commissioning Board• and must find ways of meaningfully involving their local population.
Some things remain, however, including the need to maintain financial balance at a time of an increasing aging population and very limited financial growth.
This year – 2012/13 – should be regarded as the shadow year in which CCGs will need to gain the respect of their practices, go through the authorisation process and keep costs under control.
Developing the leaders of the new organisation is only part of the story in that no matter how competent the organisation, it is essential to develop the right commitment from constituent practices.
RCGP CENTRE FOR COMMISSIONING The RCGP Centre for Commissioning was set up in 2010 to equip its members with the skills, competencies and expertise required to deliver effective clinical commissioning.
Clinically-led commissioning is a continual process of:• analysing the needs of a community• designing pathways of care• specifying and procuring services • monitoring services to ensure they improve agreed health and social outcomes, within the resources available.Good commissioning places patients, as individuals, at the centre of the process requiring a very different approach, but building up from a practice base.
THE CLINICAL COMMISSIONING CYCLE – KEY PRINCIPLES AND VALUESClinical commissioning groups, local authorities and others need to work together to plan and deliver better integration of local services.
While competition can be a means to an end, the language of the market should not be allowed to replace our first duty to improve the health and wellbeing for our patient and local population within the resource available.
Effective commissioning should be based on the following core principles:
• collaboration – working with the full range of partners to develop effective, sustainable and integrated healthcare systems• community focused – engaging local people and communities throughout the commissioning cycle and prioritising the needs of patients and the public• comprehensive – meeting the healthcare needs of the whole population, including the disadvantaged and the vulnerable to improve health outcomes• clinically-led – putting clinicians at the heart of designing and delivering innovative, evidence- based and high quality healthcare services.
This is the first real test for CCGs, to establish the right relationships, values, clinical strategies and processes if they are to really transform the local system.
This article is adapted from ‘Principles of Commissioning Summary’, one in a series of resources produced by the RCGP Centre for Commissioning (http://www.rcgp.org.uk/centre_for_commissioning.aspx)
“This year should be regarded as the shadow year in which CCGs will need to gain the respect of their practices, go through the authorisation process and keep costs under control”
UPDATESHOW PREVIEW
08 | MAY/JUNE 2012
CommissioningShow guide 27-28 June 2012
Olympia, London
The second annual Commissioning Show is set to be a good one. We bring you everything commissioners need to know to make the most of the show, including the best seminars to attend, a list of speakers and how to get there
Registration is now open for one of the UK’s largest commissioning events. With the changes well underway that will bring about a primary care-led health service, you can join over 3,000 GPs, healthcare leaders and local
authority stakeholders leading the way in delivering better patient service.
But the Commissioning Show is about much more than listening to the key issues debated by some of healthcare’s most influential figures. It’s really about the commissioners themselves and the experience they can offer each other, all the successes and cautionary tales from those on the road to authorisation – however far along.
Commissioning gives attendees the platform to put burning questions to policy makers, experts, local authorities and healthcare peers.
From round-table sessions to panel debates, you will have the opportunity to share ideas, not only with top policy makers, but with fellow practitioners who can offer practical ideas and inspiring case studies.
It is the only event where all the individuals shaping the future of healthcare will be in the same place, from GPs, to healthcare managers to local authority to public health and social care. It is the place to get face-to-face with the future of healthcare.
WHAT’S NEW FOR 2012?• Best practice working with local authorities • Technology hot topics • Table your own round table• Book one-to-one sessions with experts• Hands-on facilitated workshop sessions.
MAY/JUNE 2012 | 09
UPDATESHOW PREVIEW
COUNTING DOWN TO IMPLEMENTATION Moving towards implementation will be the main thought on the minds of clinical commissioning group (CCG) leaders when they come to the 2012 Commissioning Show in June.
Their main concerns will be around the practicalities of getting themselves ready to start commissioning, says Dr Charles Alessi, chair of the National Association of Primary Care and a member of the Clinical Commissioning Coalition, run jointly with the NHS Alliance.
One of the challenges will be for CCGs to understand what their responsibilities are around the use of any qualified provider (AQP).
The Coalition recently forced the Government into a U-turn on the use of AQP with commissioners now entitled to decide if and when they open up services to competition.
“Now we can use AQP in a way in which everybody will be comfortable with. CCGs may use it or not as they wish,” Dr Alessi adds.
Dr Alessi, who is speaking at the Commissioning Show, says that delegates will be wanting to find out more about what commissioning means, understanding how to commission, how to use health and wellbeing boards and what authorisation means.
“At the moment CCG leaders are not feeling confident. We are still at the stage where we are going through a messy transition. It’s inevitable.”
HEALTHCARE LEADERS TO DEBATE CHALLENGES FACING CCGSSetting the quality and patient safety agenda, while managing finances, is set to be a key theme of a leaders symposia, sponsored by Capita, which closes the first day of the conference.
Four national healthcare leaders will give their opinion on the immediate implementation challenges facing CCGs and how these problems can be overcome.
The debate promises to be stimulating with
the speakers including Dr Alessi; Peter Swinyard, chair of the Family Doctor Association; Dr Michael Dixon, chair of the NHS Alliance and Professor Steve Field, chair of the NHS Future Forum. The session will be chaired by Beverley Bryant, MD of Capita Health.
While current attention is inevitably focused on the need to achieve authorisation, the underlying challenge facing CCGs remains the need to sustain patient safety and quality whilst realising £20bn of efficiency improvements. In addition, many CCGs across the country will inherit health economies that are either already financially challenged or unsustainable over the long term in their current configurations.
Andrew Lawrence, Capita’s MD for commissioning, commented: “Post-authorisation is when the task of implementing innovative forms of commissioning begins in earnest. The need to embrace new ways of working will be vitally important to bring long term stability to many health economies.
“It needs to start with applying commissioning techniques which are grounded on practice populations and help better coordination across health and care services. CCGs will also demand information tools increasingly driven by real-time data, enabling clinicians to anticipate patients’ needs for healthcare services before, rather than after, they are incurred.
“Better information coupled with the increasing use of outcome-based contract levers and incentives, means CCGs have a real opportunity to influence priorities and drive improved provider performance.
“This is when the work of authorised CCGs really begins.”
For more information, or to view the full programme of events, visit CommissioningShow.co.uk.
UPDATESHOW PREVIEW
10 | MAY/JUNE 2012
LIST OF SPEAKERSPlenaries, keynote workshop speakers and chairs are set to include:• Andrew Lansley, secretary of state for health• Mike Ramsden, chief executive, NAPC• Dr Charles Alessi, chairman of the NAPC and senior GP partner (top left)• Dr James Kingsland OBE, GP and NAPC president • David Colin-Thome OBE, chair Primary Care Commissioning (PCC)• Dame Barbara Hakin, national MD of commissioning development (bottom left)• Cynthia Bower, chief executive of the Care Quality Commission• Dr Johnny Marshall, executive member, NAPC• Dr Michael Dixon OBE, chair NHS Alliance• Roger Hymas, chief executive of Healthcare Commissioning Services• Dr Gillian Leng, deputy chief executive, NICE• Mike Farrar, chief executive, NHS Confederation• Julian Patterson, director of marketing and communications, Primary Care Commissioning (PCC)
GETTING THERELondon Olympia is an easily accessible venue from all forms of transport, including Heathrow and Gatwick airport, all major railway stations and motorway routes, as well as by underground and British Rail.
Olympia has its own dedicated overground railway station: Olympia-Kensington (Olympia). Turn left out of the exit of the station onto Olympia Way and follow signs for Olympia Two and Olympia Conference Centre. Direct trains come regularly from Clapham Junction, Watford Junction, Milton Keynes and stations in between. Further direct services connects the overground with Shepherds Bush, Willesden Junction, West Hampstead, Finchley Road, Camden Road, Caledonian Road, Dalston, Hackney Central, Stratford and stations in between.
Olympia is served by the following bus routes: Hammersmith Road: 9, 10, 27, 28; Holland Road: 49; and North End Road: 391.
DRIVING DIRECTIONS TO OLYMPIA
From M1/A1/M11/A10 take the A406 westbound to A4. Continue on A4 over Hammersmith Flyover, turn left onto the B317 (North End Road) and follow signs.
From M4/A4 follow directions as above.
From A3/M3 follow signs for central London, take Wandsworth or Putney Bridges.
From Wandsworth Bridge, turn left onto New Kings Road, turn right onto Fulham High Street, which becomes Fulham Palace Road. At Hammersmith roundabout turn right onto Hammersmith Road and follow signs.
From Putney Bridge, turn left onto Fulham Palace Road and follow directions as above.
From M2/M20/A2 follow signs to central London, take Blackfriars, London, Waterloo, Vauxhall, Southwark, Chelsea or Battersea Bridges, turn left along Embankment and follow signs.
From A12/A13 follow signs for central London towards Tower or London Bridge. Do not cross bridge, instead continue along Embankment and follow signs.
Earls Court and Olympia are easily accessible from London’s four airports - Heathrow, Gatwick Stansted and City Airport - via underground and mainline rail services.
From Heathrow airport Take the Piccadilly line to Earls Court. For Olympia, change onto the District Line to Kensington Olympia. Alternatively take the Heathrow Express to Paddington and change onto the District Line to Earls Court.
The address is Hammersmith Road, London W14 8UX
HOW TO BOOKFree tickets are available for readers of Commissioning Success magazine. To book yours, quote special code “CSFree” at check out on http://www.commissioningshow.co.uk/
MAY/JUNE 2012 | 11
UPDATESHOW PREVIEW
UPDATECOMMENT
12 | MAY/JUNE 2012
AUTHOR BIORoger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is also the founder of the Commissioning Community website, www.commissioningcommunity.co.uk
The future of theNHS? We’re all off to market
Now that GP-led commissioning is well and truly here, ROGER HYMAS looks at where the journey will take us
So, the era of GP-led commissioning is
well and truly under way. But exactly
where will it take us?
I was brought up in the strategic
planning school of looking at where
markets, industries, and endeavours
will end up at some fixed point in the future and
then trying to work my way back to the present. So,
if we choose where the NHS will be five years from
now – say 2017 – how different will it look from
where we are right now?
Unpopular as it will be for many, there’s
absolutely no doubt that a sophisticated healthcare
marketplace will come to exist. This is the
inevitable consequence of the provisions of the
health bill, now of course an act. This provided
even more impetus to the trajectory of creating the
marketplace that the NHS had been building for
some time.
The bigger canvas, the separation of providers
and purchasers, got started back in the Blair/Milner
era with the creation of PCTs, although the first
initiative, GP fundholding, was launched as far back
as the early 1990s. But it never really got going, nor
during their brief existence, did PCTs get themselves
into a position to have any real market influence.
Now GPs are being given the purchaser role and
will commission healthcare for their populations. I
think GPs, as they learn their role and adapt to the
prevailing circumstances, will just make it happen.
It’s their turn to line up against the large FTs and put
their countervailing business strategies in place. I
think GPs will relish the task: it’s just possible that
they will find both the expertise and assertiveness
that was missing during the PCT regime.
Three years ago I had a ringside seat and a
glimpse of the future in a tussle between a PCT
(its next door neighbour had gone bust and seen
its senior management get fired en masse) and
the hospital – a recent foundation trust – that was
deemed to be overtrading. The PCT wouldn’t sign
its contract until it was certain about the hospital’s
activity level. The PCT put the hospital onto a block
contract – passing 1/12 of the prior year’s budget to
the hospital on a monthly basis. The hospital went
bust, most of the board got fired and the secretary of
state bailed out the trust, with a long-term loan with
significant strings attached. It’s possible that we’ll
start to see this sequence of events replaying itself
all over the country in the next few years, certainly
within our chosen time frame of 2017.
So, I definitely expect to see the NHS in England
to evolve to be a complex, sophisticated market,
although it will never be a perfect one. There will be
MAY/JUNE 2012 | 13
UPDATECOMMENT
built-in distortions, usually politically-driven,
usually justified as a need to protect the
public interest. The Government’s inability to
separate the secretary of state from the NHS
during the passing of the act means that the
market for a long time into the future will be
vulnerable to political manipulation.
Markets always need a cast of engaged
players so how will they line up and what
will be the motivations which drive their
behaviour?
COMMISSIONERS NOW CCGS AND GPS
We start with 212 CCGs, which means an
average of around 200,000 patients each, too
few for real economies of scale in back-office
administration or to build viable risk pool.
To date, we’ve had little guidance from
the DH about how it plans for risk to be
managed, but for the players involved, it will
in the future influence much of their own
decision-making, particularly as they learn
the terms of market engagement.
It’s likely that the really large risks will
end up in a regional pool under the control
of a specialised commissioning group.
Around £30bn has been set aside to manage
specialised risks and pay for complex cases.
There are huge opportunities for savings in
this sector and I see it as a smart move by
the NHS Commissioning Board to assume
responsibility for the SCG risk pools. This
arrangement will provide the scope for a range
of procedures to move in and out of the scope
of specialised commissioning and provide
headroom to help balance CCG, and therefore
NHS, budgets.
Having as many as 250 CCGs may have
its downsides, but it will promote locality
commissioning, which I see as a real benefit.
The CCG meetings I’ve been to recently are
already beginning to understand the value
of community commissioning. Most GPs
like working at this level of scale. Certainly,
a sense of collectivism, federation even,
is starting to build, which I think will be
positive for local healthcare.
But, ‘localism’ in healthcare has a
downside and that is in treatment practice
variation. There is a phenomenon in health
economics called ‘The surgical signature’.
This occurs because health systems have
normally grown around a dominant
neighbourhood hospital and local health care
is hugely influenced by the customs and
practice of that hospital. Also, local healthcare
practitioners are very protective of their DGH
– even if its quality in some aspects of delivery
is sometimes dubious – adopting a kind of
reverse nimbyism. The practices, processes,
motivations and ambitions of the local DGH
will have a huge influence over variation and,
therefore, quality of outcomes.
That’s why NHS Choices is a significant
part of the DH policy agenda. Expect the
push to quality measurement to increase
competition and widen hospital catchment
areas as patients travel further for a higher
quality solution. Hospitals will start to make
access easier, particularly for conditions,
procedures, where they want to build market
share and attract high value patients.
PROVIDERS
This covers the range from large foundation
trusts all the way down to GP practices that
do the odd procedure or diagnostic test.
NHS budgets are finite and with the
growing pressure on government finances,
funding is going to get much, much tighter.
Arguably, the healthcare market is currently
over-supplied. Even though that is the case,
there’s been a huge resistance to closing
or downsizing hospitals. Providers seeking
to build market share will create the new
battleground: to keep on growing – and
businesses have to – DGHs will be seeking to
take business from their neighbours, starting
where their catchment areas overlap. But the
biggest feature – and this is the game changer
– is that it’s GPs, historically the gatekeepers,
will become supply chain managers. Top
of their minds will be the need to regulate
demand and control supply to ensure that
their CCG does not go bust. Local tariffs will
begin to push down national rates. Those
providers with the highest cost bases (usually
those carrying the biggest overhead) will come
under the most financial pressure. The signs
are there already.
Most GPs, of course, already double-up
as providers. They always have done. But in
the future many more will see the financial
benefit of expanding their providing capability.
All GPs will assume a commissioning role
and many will recognise that the requirement
of balanced budgets will require them to move
their patients to the lowest cost solutions,
often provided not by hospitals, but by their
GP colleagues.
THE NHS COMMISSIONING BOARD
While its principal role will be to regulate
primary care, as far as CCGs are concerned,
the NCB will often seem to them to be the
government enforcer. Most of the NCB staff
comes with a cultural orientation towards the
provider interest. There is no strong tradition
of commissioning experience among DH/
NHS officials and they will struggle to adopt
a true commissioning mind-set. None that
I know of has had first-hand experience as
a commissioner in industrial-scale health-
care: for example, nobody senior has worked
in the US HMO industry. There are plenty
of statisticians and economists in the DH,
but no actuaries, the real controllers of
commissioning finances.
This could mean, rather bizarrely, we
could see a disconnect between what the
Government wants to see delivered and what
gets done. Creative destruction doesn’t sit
very well with healthcare systems, although
perversely it is an essential driver of medical
technology and pharmacology progress.
Local health economies are notoriously
conservative and resist change. They don’t do
the radical as Andrew Lansley will now attest.
When it’s attempted, every big bang change is
opposed by equal and opposite resistance.
COMMISSIONING SUPPORT SERVICES
These will have a huge role to play as the
CCG back office. CCGs are well advised
to spend the maximum attention over the
next twelve months to researching and
contracting their support arrangements.
A poor CSS will be a critical factor in
frustrating CCGs’ own ability to deliver
commissioning effectively, in the worst case
leading to its downfall. CCGs will be free to
choose wherever they get the service in the
market: they should spend as much time
as they need making sure that they get the
right help. They should beware of snake oil
doctors – this is a tricky environment for
inexperienced purchasers. Certainly, CCGs
would be well advised to avoid long-term
contracts in the first instance.
LOCAL AUTHORITIES
These will have a new and expanded role
in health care. Expect many of them to
be assertive in defending the needs of
local populations, particularly in the big
conurbations, where they
UPDATECOMMENT
14 | MAY/JUNE 2012
will see the importance of
plugging the commissioning
and public health management
gaps when SHAs go away. They
and CCGs should create strong
working relationships.
PATIENTS
These can be grouped into a
variety of guises – consumers,
users, patients, carers, the public.
What you can be certain about
is the coming patient typologies
are going to be different from
previous generations, particularly
those who benefitted hugely
from the invention of the NHS
and have been forever grateful
for it. But the new force in
health care consumerism will
be the baby boomers who have
a completely different attitude
to life – and death. They will be
active, assertive, increasingly
vociferous, even strident,
consumers. We should expect a
good measure of patient activism.
Consumers will respond to
changes in care patterns, given
the right incentives. As they
do for everything else they buy,
they will look for quality and
convenience. Many patients,
particularly those with mobility
issues, will value not making the
trek to hospital. Local tests (at
the surgery), Skype consultations,
home care (yes, it will resurge)
are all part of the future. Ask
any high street retailer to tell
you what happens if you lose
customer footfall. Business falls
off rapidly. Look at the success
of the Internet – Amazon and
the like. It’s the triumph of
consumer self-interest. Providers
will learn how to bundle the best
care with the best amenities.
“The Government’s inability to separate the secretary of state from the NHS during the passing of the act means that the market for a long time into the future will be vulnerable to political manipulation”
If I were a major provider,
I’d build bigger car parks, but
charge nothing for using them.
In major cities I’d put a free
return taxi trip into the high
margin procedures which my
service line analysis tell me is
where I make good profits. They
will restlessly pursue the health
care solutions which they think
are best for them, increasingly
relying on the Internet and will
always respond to the best offer.
What I don’t think has yet
soaked into the consciousness
of most people is just how very
different the future is going
to be. The large providers are
reckoning on demand going
up continuously; it’s firmly
build into their business
plans. Certainly, all the signs
– demographics, technology,
consumer demands – look like
they’re pointed that way. For
the next twelve months as we
transition from PCT-led to
CCG-led commissioning, true,
it’s not going to look like many
of the other years since 2006,
when PCTs got going. But a lot
of lessons are going to start to get
learned very quickly this year.
GPs are a wily bunch and will
quickly start to work out the
angles. This is the way they’ve
always managed the NHS: and
now they’re in control.
What I’m predicting is that
subtly, but inevitably, the reality
of a market place is going to
come into shape. And subtly and
slowly is the way that health care
markets go about change. It’s the
little movements which happen
one by one, mostly on the margin.
Healthcare is conservative. It
changes incrementally, patient
experience by patient experience,
but change it will.
The first trend we’ll see is
for GPs to refer fewer patients
to hospital. There will be local
substitutions – a GP provider for a
hospital; or a community trust for
a hospital; under patient choice,
an independent sector provider
for an FT. New care pathways
will be tried out and slowly
become the convention. Indeed,
this is the essential pre-requisite
to revolution. Patients will only
move to new solutions when
everyone is confident that they
will deliver safely, another given
of a conservative market place.
Now all what I’ve just
described, of course, added
together, begin to look like the
characteristics of a classic health
insurance market. This is where
I know, emotionally, I’m going
to lose a lot of you. Many NHS
stalwarts don’t like the analogy
I make between the US system
and the future health service in
England. But, I’ve observed the
evolution of health care markets
on both sides of the Atlantic for
20 years. I can tell you that all the
factors I’ve listed began to happen
in the US as long as 25 years
ago. This means that certainly
within the next five years we’ll
see CCGs begin to behave like
HMOs or health insurance plans.
MAY/JUNE 2012 | 15
UPDATECOMMENT
outcomes. That’s their principal
role. New measures of efficiency
will also need to be sought out:
outcomes, outputs, will always
be more important than inputs.
That’s what good commissioning
always delivers.
Practice data are the new
crown jewels. Providers will
want them, as well as Big
Pharma, actuaries, re-insurers,
econometricians, Public Health,
even geneticists (the Human
Genome plays a key part in
future personalised medicine).
Analytics will get more
sophisticated the nearer you
get to the end game, because
knowledge is genuinely power.
Commissioners will learn to
invest more in commissioning
practices where they deliver good
value. Return on investment
– what you get out of your
commissioning spend – then
becomes a more important
consideration than the current
arbitrary and paltry allocations of
cash for commissioning support.
Like insurance companies,
CCGs will invest more on back
office systems to drive down
claims cost. The NHS has
to adopt insurance company
conventions. But it will do.
Start out by checking what ‘loss
ratio’ and ‘expense ratio’ mean.
What you will find is that if
you spend £100 on improving
commissioning intelligence and
save £500 on the care bill, or
£10,000 and save £200,000, you
should always spend the money.
You have a positive return on
the investment. The £100 or
£10,000 are the Expense Ratio,
the £500 or £200,000 are the Loss
Ratio. That’s why the piddly
amounts of money allocated to
CSS are a false economy and a
complete policy mistake. This
comes about because politicians
and DH officials, sensitised
about bureaucracy and its cost,
don’t understand that you have
to spend as much money as
necessary in rooting out the costs
in the system and then finding
ways of reducing them. Everyone
will soon learn, it’s part of the
journey.
So, when you add all of this
together, all of the players in the
new market place will become
engaged in what can only be
described as a kind of Darwinian
mash-up. But what you can be
absolutely certain about is that
each will be out to protect and
promote their self-interest.
So, by 2017, what can we
expect? A rapidly contracting
hospital base. Many specialists,
maybe single function providers
– close to surgeries, certainly
more GP provider businesses.
The number of CCGs staying at
about 250, but only as locality
commissioners. We’ll probably
be down to 50 risk bearing
organisations. CSSs going from
25 to 15 to 5, most of them
private providers, although GPs
will work out that it would be
best if they controlled them,
not surrendering them to the
big BPOs.
What I’m saying to you
is that the NHS landscape is
going to be completely different.
Because of the changes which
will take place, so will be your
role. Just you wait and see. Better
still, get out there and start
deciding your own future. Before
somebody else does.
The rest then, and particularly
the way the players continuously
adapt and modify their roles
in a market place, means that
everything else falls into place.
Excellent business services
are required to support CCGs.
This is why getting best quality
commissioning support is so
vital to the success of the future
NHS. For a start, the dependence
on analytics will strengthen. In
a healthcare market, everyone
wants to see the evidence. The
data covering ‘claims’, provider
invoices, will be the centrepiece
of the metrics as they are critical
to managing costs. The benefit
of tracking the money becomes
paramount, because this will help
CCGs understand financial risk,
and how they can avoid it. Expect
in time that every patient pathway
will have its own P&L account.
Measuring outcomes to drive
quality will be a big feature,
arguably the most important one
for driving the next generation
of NHS policy. And, of course,
GPs are in the best place to both
observe, manage and influence
outcomes as they navigate and
manage patients through the care
system. This means that both
patient experience and patient
satisfaction will become key
measures, particularly as self-
interested baby boomers look to
secure the best possible experience
for their health condition.
All this takes us to the
inevitable conclusion that
commissioning evolves to be
a management science. CCGs
will expect CSSs to help them
search for the best, most cost
effective way of achieving the best
SPONSORED FEATURENUTRITION PRODUCT FUNDING
16 | MAY/JUNE 2012
Is your secondary care provider shopping with your commissioning credit card? The current funding model for malnutrition
THE BACKGROUND
Malnutrition appears on the radar of commissioners largely as a
result of a medicines management drive to reduce expenditure on
Oral Nutritional Supplements (ONS). However, there is a lot more
to this complex and fascinating subject than meets the eye. Most
health economies have a contract with one of three main providers
usually associated with ONS and Enteral tube feeding (ETF) and
encompass primary and secondary care, directly or indirectly.
Historically, these contracts have been driven by procurement
teams with an acute trust perspective. Over the years, this has
evolved into a model where competitive procurement has driven
down the cost to the acute trust (ONS and Tubes) at the expense
of PCTs who inadvertently protect secondary care activity through
primary care prescribing of ONS and tube feeds at approved
ACBS/NHS prices. That said, overall the procurement process has
managed to extract good value for the health economy as a whole,
with primary care also getting additional value from contracts
such as discounted giving sets and free delivery. Overall though,
in simple terms, secondary care has been driving the purchasing of
these products and driving value for the whole health economy but
primary care has been footing the bill!
WHY WE NEED TO UNDERSTAND MALNUTRITION IN AN
OUTCOME-DRIVEN NHS
There is strong evidence for managing malnutrition and by doing so
appropriately, it can deliver:
• 27% reduction in admission rates and readmission rates1
• Reduce length of hospitalisation by 4.5 days2
• Reduce complications such as pressure ulcers by 19%3 and
antibiotic use by 56%4
Moreover, results and reduction in costs can be realised in a very
short time frame - months, in fact, not years. NICE recognises it as
No. 3 of all of the NICE clinical guidelines that it has produced for
delivering substantial cost savings? 5
WHICH PATIENTS ARE ONS AND TUBE FEEDS APPROPRIATE FOR?
Whilst the evidence for the use of ONS is compelling, they can be
subject to inappropriate use, wastage and stock piling. It is clearly
in everybody’s interest to see them used appropriately. NICE
recommends their use in high risk patients identified through
MUST screening, although commissioners might want to
prioritise certain groups such as those with COPD, dementia,
pressure ulcers, people recovering from surgery and those with
swallowing difficulties.
ETF is used to feed patients who cannot attain an adequate
oral intake from food and/or oral nutritional supplements, or
who cannot eat or drink safely. The aim is to improve nutritional
intake and so improve or maintain nutritional status. It is used
most commonly in patients with dysphagia either because they
cannot meet their nutritional needs despite supplements and/or
modifications to food texture/consistency, or because they
risk aspiration if they try to do so. Other indications for ETF
include (not exhaustive) Post CVA, multiple sclerosis, Motor
Neurone Disease, Parkinsons Disease and GI dysfunction
or malabsorption.
References:1. Stratton RJ et al. Clin Nutr Supplements 2011;6(1):16. 8. Cawood AL et al. Clin Nutr
Supplements 2010;5:123. 2. Cawood AL et al. Clin Nutr Supplements 2010;5:123. 3. Stratton RJ et al. Age Res Rev 2005;4(3):422-450. 4. Cawood AL et al. Proceedings of the Nutrition Society 2010; 69 OCE7, E5445. NICE Cost Saving Guidance. April 2012 http://www.nice.org.uk/usingguidance/
benefitsofimplementation/costsavingguidance.jsp
SHAILEN RAO, MD SOAR BEYOND LTDSERVICE PROVIDER OF MEDICINES MANAGEMENT SERVICES TO PCTs AND CCGs.
MAY/JUNE 2012 | 17
SPONSORED FEATURENUTRITION PRODUCT FUNDING
HOW HAS SECONDARY CARE BEEN SPENDING PRIMARY CARE
MONEY? - DESCRIPTION OF THE MODEL
The current model consists of 4 elements across primary and secondary
care (figure 1). This comprises tube feeds and ONS across primary and
secondary care respectively. Existing contracts generally cover both
ONS and tube feeds in secondary care and tube feeds in primary care
(the darker shaded portion of the grid), with an expectation that primary
care prescribing for ONS will also be for the contracted product, driven
by choice in secondary care. The contracting process is generally led by
secondary care and typically, ONS and tube feeds are heavily subsidised
in secondary care – often supplied for a penny each! Suppliers then
depend on continued prescribing of their products in primary care to
recoup the heavily discounted prices in secondary care. Over the years,
the competitive nature of this market has enabled NHS procurement
teams to extract ever increasing value. For instance, many tenders
for these contracts will require bidders to fund clinical posts (usually
nurses or dietitians) and even staff training. The nurse teams are
aligned to the NHS agenda i.e. work to get early discharge and prevent
re-admission. In addition, prescription processing is provided, such
as stock control to reduce wastage (including management to reduce
prescribing, where appropriate), accuracy checks to ensure patients get
the right treatments for safety as well as free delivery and associated
equipment such as pumps. A list of product and service elements
included in a typical contract is given in Figure 2.
WHY COMMISSIONERS NEED TO ACT NOW
As we can see from Figures 1 and 2, the NHS has been getting great
value when the model is viewed as a whole across the entire health
economy. However, PCTs have been targeting ONS in isolation and the
reduced spend here is threatening the future viability of this model.
In fact, in addition to a general lack of awareness of the model
amongst primary care commissioners, there is also a lack of
awareness of the clinical and cost-effectiveness of ONS (when used
appropriately), leading to an imbalanced approach of simply reducing
or even stopping ONS use completely, rather than driving appropriate
use that encompasses initiation of treatment in those with appropriate
clinical need. If the current direction of travel continues, there is a real
risk that certain contracts will no longer be viable as providers pull
out of contracts or put their prices up and the health economy will be
forced to pay more. On a more positive note, there is an opportunity
for commissioners to take hold of the reins and re-focus the existing
model; moving away from the existing paradigm which is a product
procurement driven approach to a model that is commissioning led
and QIPP-oriented. This is more likely to deliver appropriate clinical
and financial outcomes (reduced avoidable hospital admissions and re-
admissions), whilst maintaining the excellent quality and value being
delivered currently, especially relating to tube feeds.
WHAT COMMISSIONERS NEED TO DO
Although it is tempting to wipe the slate clean and re-balance the
contracts so that primary and secondary care pay for exactly what each
uses, the practical difficulties make this a complex option, at least
to attempt it in one monumental step. The reality is that the model
viewed in its entirety, works well across a whole health economy and
starting from scratch could lead to increased costs overall. Having
shared this model with commissioners, the unanimous view is that
the most prudent approach would be to engage local commissioners,
expert clinicians (especially dietitians) and the provider companies
of nutrition products to work out the best model going forward. A
commissioning-led solution could actually provide an opportunity to
embed service specifications for malnutrition management within
contracts of existing providers including GPs, community service
providers and acute trusts.
Below are some questions you should ask yourself about your
local contracts. If you answer “NO” or “DON’T KNOW” to any or
all of these, it is time to probe into your contract arrangements to
make sure that you are fully aware of the value you are getting and to
ensure your health economy is not spending more overall. In fact, by
doing so it could enable you to obtain real improvements in clinical
and cost-effectiveness... now that really is worth getting your credit
card out for!
Service component Charge to secondary care Charge to primary care
Tube Feeds 1p ACBS Approved price
Plastic giving sets 1p 1p
Deliveries (feeds and ancillary items) to patients
Free Free
Pumps On Loan ( no charge) On Loan ( no charge)
Out of hours phone helpline Free Free
Oral Nutritional Supplements
1p ACBS Approved price
Clinical Nurse Post (numbers stipulated in tender)
Free Free
Figure 2: What might be included in a typical contract
This article was supported by an unrestricted educational grant by Nutricia Ltd. Nutricia are providing external facilitation and contract review meetings with key stakeholders to raise awareness and help you to understand your local arrangements. Please contact [email protected] for more information.
Secondary Care Tube Feeds
Primary Care Tube Feeds
Primary Care ONS
Secondary Care ONS
The Funding Model for
Malnutrition
Figure 1: The Funding Model for ONS and Tube Feeding:
The dark shaded areas represent what is typically included in the contract, whilst ONS in Primary Care (light blue) is not
QUESTIONS FOR COMMISSIONER:
• Do you know your current procurement arrangements?
Who is your contract with?
• What is included in the contract? Do you receive any
value-added services, such as funded posts, rebates etc?
• What is the total contract value and are you receiving value
from it? When is your contract up for review?
IN ACTIONCASE STUDY
18 | MAY/JUNE 2012
Happy together
DR TIM DALTON, clinical chair of Wigan Borough Clinical Commissioning Group
and COO Trish Anderson, take a big picture approach to commissioning. They tell
JULIA DENNISON about their innovative integrated care model, and how campaigns like Breathless, which addresses asthma, COPD and heart failure under one pathway, help bring health and social care together
The integration of healthcare into
the community is obvious the
minute you set foot into the
Wigan Life Centre, home to Wigan
Borough Clinical Commissioning
Group. The CCG’s HQ is located
in a building that plays host to a number of different
social and health care services and its open-plan
office overlooks a public pool and fitness centre – so
the local population is never too far out of sight. The
physical structure of the building is symbolic of the
CCG’s larger approach to integrating health and social
care in a unique and forward-thinking manner.
When I visit clinical chair Dr Tim Dalton and
chief operating officer and interim accountable
officer Trish Anderson, it’s April, the time when
commissioning groups like Wigan Borough were
just coming into shadow form. Dr Dalton sits on
the commissioning board as lead clinician, while
Anderson is lead manager – and both have high
hopes for rolling out their innovative integrated care
model to the local community.
DOCTOR KNOWS BEST
Dr Dalton considers himself a GP first and foremost,
having worked in general practice in Wigan for
12 years prior to his post on the CCG board. His
MAY/JUNE 2012 | 19
IN ACTIONCASE STUDY
“raison d’etre”, he says, is training and quality. Indeed, his practice, Shakespeare
Surgery, where he is a partner with two other GPs, was the first single-handed
training practice in the North West and his team worked closely with the PCT
to set up a group of clinicians focused on improving quality across the locality,
particularly around pathway design and implementation. It was a natural
progression for him to move on to practice-based commissioning, at a time
when the Framework for Procuring External Support for Commissioners (FESC)
process was underway. “It allowed the PCT to really engage with clinicians,”
Dr Dalton remembers of PBC. “Historically, at that stage, we had been held at
arms-length and we were part of the problem, not the solution, and that allowed
us to get into the [commissioning] space.”
As part of this process, a number of local practices started to group
together to form groups covering around 50,000 patients each, which began
meeting on a monthly basis. “[To date], GPs have been peers, but have been
suspicious of each other,” Dr Dalton explains, “by getting into a room on a
monthly basis and to talk and exchange ideas, it starts to build a different
ethos of trust and cooperation.”
SHARING AN UMBRELLA
This cooperation and trust would become beneficial when those groups would
merge to become five localities under Wigan Borough CCG. In the first wave of
pathfinder applications, five localities in the Wigan area had applied to become
separate CCGs, but were unsuccessful. Four of the five came together under a
federated application for the third wave of pathfinders and it was accepted. The
fifth locality – United League Commissioning – has since joined forces with
Wigan Borough due to receiving a few red flags on its first gateway assessment.
It’s been important to the ethos of the CCG to keep those locality groups
under the larger umbrella brand, and they have been careful to formalise
that federated agreement. “For us, CCGs are [built] around practices working
together,” says Dr Dalton. “You can’t put 52 practices into a room; you can put
10 or 15 into a room and have some genuine dialogue.”
A MANAGER WITH A DIFFERENCE
Putting these ideas into play takes good management strategy, and this is
where Anderson comes in. Her background is in health and local government,
previously working for the council as a director of children’s services. She came
over to work for the PCT as deputy to its chief executive, who was also heading
up the local authority as well. She’s local too, having worked in Wigan for 25
years and knew many of the stakeholders already.
Anderson, Dr Dalton and the rest of the CCG’s commissioning board
felt it was absolutely imperative to treat the commissioning group as a new
organisation, and not get hung-up on how things used to be under the PCT.
This comes down to setting different value sets and cultural aspects inside
the organisation, while putting quality, clinicians and patients at the heart of
every decision.
MORE THAN JUST PATIENTS
The group is also very focused on integrating services across the entire
spectrum of health and social care. This is an ambition they share with the
local authority, which also happens to be housed on the same floor of the
Wigan Life Centre, making it logically a lot easier for the CCG to collaborate
with them on services. It also means that the people of Wigan are not just
treated as patients by the CCG and residents by the local authority, but
citizens who have a right to live comfortably. Integration lies at the heart of
this ethos.
IN ACTIONCASE STUDY
20 | MAY/JUNE 2012
“If you’re going to make the whole system work, within the financial
constraints that all of us have, you can only do it if you [integrate care],” says
Anderson, pointing to the fact that an aging population means many of the
patients in the area will be using a number of different health and social care
services. “Our commitment really is to get the integration working right the way
through.”
STOP AND BREATHE
One example of this integration of care and quality includes a scheme the Wigan
groups started just over a year ago called Breathlessness, which looked at ways to
integrate COPD, asthma and heart failure pathways for the many patients who have
all three conditions. “We recognised the problem when people bouncing between
three really good pathways with three really good teams weren’t getting better or
were still ending up in hospital,” explains Dr Dalton. Around 18 months ago, the
locality groups went back to their practices to come up with a solution. “We came up
with a very different model,” he continues. “This was very much a facilitative way
[of working], where we brought all the current providers into a space – that was the
community teams, the secondary care teams, the GP teams – but we also brought
patients, third-sector providers, finance and commissioning people into that space
[too]. We started to thrash out a truly integrated service where people would have
breathlessness as a problem and the team would help diagnose, manage and pass
back. So it was very much about an empowering process and it equally linked into
the social healthcare needs.” The model that came out of it was a diagnosis process
and then a management process, which covered everything from smoking cessation
to heating allowances, and therefore acts as an exemplary model of health and social
care working closer together.
The proof is in the pudding and the results from the Breathlessness pilot give that
proof. As a result of the scheme, there was a reduction of hospital admissions in the
area covered by the pilot compared to the rest of the patch, where admissions had
actually gone up; the number of outpatients plummeted; the quality and accuracy
of prescribing vastly improved – which has had a knock-on cost savings effect; and
more importantly, the patients were happy with it. The CCG commissioned Ipsos
MORI to survey the participating patients and the feedback has been very positive.
“The patients have really started to understand what’s wrong with them and what
they need to do when they get poorly,” explains Dr Dalton. “They’ve really started to
be empowered to actually make a difference and that’s probably the biggest win from
this. There’s all that financial stuff, but patients are actually in charge of what’s going
on with them and are much more self-confident and that’s what’s led to the reduction
of admissions because there isn’t the anxious, help-seeking behaviour because they
know what to do.”
This approach to the patient as a whole person is what makes commissioning in
Wigan so successful. “Social care faces the same challenges and often the solution is
the same for both sides of the process,” adds Dr Dalton. Indeed, it seems, if CCGs are
to meet the Nicholson Challenge, they can’t do it without patients and social care on
their side.
“If you’re going to make the whole system work, within the financial constraints that all of us have, you can only do it if you integrate care”
FACT BOX CCG Wigan Borough
PRACTICES 65
PATIENTS 320,000
EXECUTIVE BOARD 10 people, comprising five GP leads, a chair, an accountable officer and a chief finance officer and two laypeople. They are actively recruiting a secondary care doctor and nurse.
POPULATION to patient:The challenges of integrated diabetes care
MANCHESTERWednesday 4th July 2012
BIRMINGHAMThursday 5th July 2012
NEWCASTLETuesday 10th July 2012
LONDONWednesday 11th July 2012
LIVERPOOLTuesday 17th July 2012
View the agenda and register FREE atwww.pri-medupdates.co.uk/p2p
For more information call our registration team on 0800 731 3927
Developed and sponsored by MSD Diabetes in conjunction with Pri-Med Educational Programmes Ltd
A one day educational workshop focusing onthe innovative commissioning of diabetes careAimed at healthcare professionals involved in developing and
delivering diabetes care, this workshop will examine thechallenge of integrating and optimising the delivery of
diabetes services in order to improve outcomes for patients.
DIAB-1025091-0027 May 2012
IN ACTIONCASE STUDY
22 | MAY/JUNE 2012
The dream team
Clair White and her
colleague Vikki Reed are
leading the way to better
commissioning in Durham
Dales. As the two project
leads on the Durham Dales
locality commissioning team, they lead pathway
redesign, commission and decommission
services under Durham Dales, Easington and
Sedgefield clinical commissioning group, and
are actively reducing unnecessary secondary
care referrals by providing care closer to the
patients’ homes.
The team at Durham Dales commissioning locality is making
waves with its pathfinder work, implementing a number of innovative
patient pathways despite a challenging geographic area. It’s no wonder they
have been nominated for the BMJ Clinical Commissioning Team of
the Year award. JULIA DENNISON speaks to project lead CLAIR WHITE
to find out more
IN ACTIONCASE STUDY
24 | MAY/JUNE 2012
Durham Dales recently merged with
two other localities to become one CCG,
but still actively commissions services on
its own with the support of a strong team of
clinical and managerial staff. Together, they
recognised that a new, innovative model
of care, built on robust evidence and based
around patient-centred pathways could
provide a solution to the area’s problems.
TOUGH TERRAIN
Durham Dales itself has a relatively stable
population of around 90,500 patients, but
covers a large, diverse geographical area,
which brings its share of challenges. While
the locality includes some small areas of
urbanisation, it also encompasses many
rural areas, which can be difficult for
commissioners who have to provide services
for isolated patients, often encountering
transportation difficulties on the way.
Meanwhile the cluster of 12 practices has
a prevalence of poverty-related disease that
is significantly higher than the national
average in some cases.
In the face of this adversity, the
commissioning team maintains a self-
proclaimed “can-do” attitude to moving
services closer to patients. The group of
practices achieved success in this area prior
to the existence of clinical commissioning
as part of a Department of Health-funded
Integrated Care Organisation (ICO) pilot
from 2009 to 2011.
As part of the ICO, the Durham
Dales teams undertook several successful
work streams, eight of which have been
developed further by the CCG since
it gained pathfinder status, covering:
care closer to home for diabetes and
gynaecology; improving rural mental
health pathways; improving mental
health services for older people, focusing
on dementia; vascular screenings in GP
practices; better transport links; a fuel
poverty scheme to encourage GPs to use
Energy Savings Trust’s ‘hotspots’; an
urgent care work stream; and a GP bed
initiative in practices to help patient
recuperation outside of an acute
hospital setting.
REDUCING REFERRALS
When the Durham Dales Pathfinder CCG
went live on 1 April 2011, its core aim
was to reduce unnecessary GP referrals
into secondary care by redesigning
patient pathways, commissioning and
decommissioning services and providing
care closer to home.
Early outcome measures suggest the
pathfinder has been successful and is
reducing referrals into secondary care by
more than the five per cent target in the
Dales and by a significant amount overall for
County Durham and Darlington.
Activity commissioned to support the
CCG has been vast and over 20 projects have
been led and rolled out via the project leads
and the practices.
One commissioned pathway has been
around diabetes, developing a consultant
and specialist nurse-led community
diabetes service in all 12 GP practices in
Durham Dales. The CCG also entered
into a partnership arrangement with a
pharmaceutical company, which provided
them with a dedicated diabetes health
development manager (a former PCT
employee) to support the rapid roll out
and provide diabetes expertise. Another
successful pathway focused on the diagnosis
and management of IBS in primary care,
resulting in better patient care by reducing
unnecessary endoscopies and invasive
tests needed in secondary care, which also
saved a substantial amount of money for
reinvestment elsewhere.
It’s this pathway that White is most
proud of. “I very much feel we’ve led the
way,” she says of this area. “We took a leap of
faith and just had a go and piloted it, which
is what it’s all about.” As a result, there has
been much interest in the health community
around Durham Dales’s work on IBS and
the outcomes it achieves. “I’ve seen the
data on how many GI referrals wesent into
secondary care this year when compared
Durham Dales team: Clair White, Vikki Reed, Dr Stewart Findlay, Laura Kirkup and Deborah Perry
“When you mention reduction everyone thinks it’s about rationing care, and it’s absolutely not; if we can provide all these services in primary care, it just should have an impact”
IN ACTIONCASE STUDY
26 | MAY/JUNE 2012
to last year, and it’s significantly less, so
it’s clearly having an impact,” says White.
“And we’ve had huge campaigns on cancer,
which is bound to make our referrals go up,
so we know we’ve made a difference, and
we’ve probably made a bigger difference
than what we think.”
Historically, Durham Dales was also
one of the first localities in the country to
bring specialist nurses into every general
practice to run secondary care prevention
clinics for cardiovascular disease and to
look after patients with heart failure, and
this continues today. Its original service
was described by the Government’s former
national director for heart disease and
stroke, Sir Roger Boyle as “the gold standard
to which all other areas should aspire”.
More recently, the locality involved all
of its practices in looking at the prevention
of cardiovascular disease, predating the
DH’s launch of its ‘Putting Prevention
First’ initiative. They also developed the
concept of a quality contract with the
acute provider, community provider and
mental health trust. This has allowed
closer working between the locality and
its provider colleagues and, again, this idea
predated the Foundation Trust Standard
Contract from the DH.
STRONG LEADERSHIP
These pathways would lead nowhere if
it weren’t for a strong leadership team.
The 12 practices in the Durham Dales
have always worked closely together.
For many years now, they have allowed
their community nurses access to the IT
systems and made full use of electronic
path laboratory results and requesting of
laboratory tests. Working relationships
with local out of hours GP colleagues
have been enhanced with the provision of
shadowing opportunities in local practices,
ensuring engagement between primary and
secondary care clinicians.
All groups meet monthly or bi-
monthly. At these meetings all current
and developing projects and pathways are
discussed in detail before attaining sign
off by members, ensuring each project
undergoes very robust governance. As
chair, Dr Stewart Findlay ensures that
all projects are patient care-focussed and
clinically-led, while project leads, White
and Reed, work alongside the Durham
Dales practices to set priorities and
develop commissioning intentions.
In turn, these have been included in
the locality’s five year strategy and the
Durham Dales, Easington and Sedgefield’s
‘Clear and Credible Plan’, which will
be instrumental in the CCG’s journey
towards authorisation.
A GOOD WORKING RELATIONSHIP
Practice managers and GPs in the Dales
have a very good working relationship
with the commissioning team and this is
demonstrated in many ways – information
requests are dealt with in a timely fashion
by practices, something which is essential
and assists the project leads when they are
developing pathways and service redesigns.
Project leads attend all practice manager
meetings and are considered to be integral
members of the overall Durham Dales
group of practices.
Clinical leadership has been distributed
to ensure engagement and clinical input in
all areas and at all levels. All clinical areas
have a patient representative attached to
their forums and a consultant diabetologist,
practice nurses and nurse specialists are
attached to the diabetes pathway, while
a local pharmacist leads on MURs and
asthma for the locality.
The group organises quarterly, soon to
be bi-monthly, whole cluster educational
events, which have grown in popularity
over recent years and are now attended
by upwards of 200 delegates. Speakers are
sourced from around the country and all
requests for topics are considered and,
wherever possible, structured to practice
needs at one of the events. These events
have been so successful that there is now
a waiting list for speakers wishing to attend.
When I speak to White, she’s getting
ready to attend the BMJ awards, where
the team is nominated for clinical
commissioning group of the year. Whether
or not they come home with an award,
they certainly deserve the recognition for
their unrelenting ambition and dedication
to improving care for their patients in the
Dales. And there is no stopping them now:
“We’ve got loads more ideas for this year,”
says White. Plans include expanding the
IBS pathway to include IBD; introducing
teledermatology into primary care, whereby
GPs can take pictures of suspect moles,
for example, and email them through
to a consultant; ring-pessary fitting and
changing in primary care; expanding the
diabetes service; improving palliative
care and stroke prevention; stepping
up dementia screening and psychotic
prescribing; implementing physiotherapy
in all the GP practices and counselling
services; and commissioning a primary care
urology service.
The team is also keen to reduce
secondary care referrals by another five
per cent this year. To do this, White
believes all they need do is keep up the
good work. “All of our primary care and
community pathways should just make
that achievable,” she says. “It’s not about
rationing. When you mention reduction
everyone thinks it’s about rationing care,
and it’s absolutely not, but if we can
provide all these services in primary care,
it just should have an impact.” With this
commissioning teams’ track record, it
undoubtedly will.
FACT BOX CCG Durham Dales, Easington and Sedgefield
PRACTICES 41
PATIENTS 280,500
COMMUNITY CAREREDUCING ADMISSIONS
28 | MAY/JUNE 2012
Saving the NHS from bankruptcy
PAUL ROBINSON analyses trends in hospital admissions, and offers starting advice on reducing both elective and emergency admissions in your area
MAY/JUNE 2012 | 29
COMMUNITY CAREREDUCING ADMISSIONS
“More hospital admissions runs the risk of taking all growth monies in future”
Whoever you choose
to believe about
the extent of the
national debt
and the reasons
behind it, the
future impact on the NHS is inalienable.
Nine tenths of healthcare treatment might
take place in primary care but in terms of
spend, hospitals care accounts for 52% of
PCT expenditure. Analysis by healthcare
intelligence firm CHKS shows that hospital
admissions are still on the rise and could
bankrupt the NHS – so what can be done to
encourage the shift away from hospital care?
A good starting point is to examine the
increase in hospital admissions in more
detail to see if that throws any light on what
the possible drivers might be. The figures
from CHKS certainly make disappointing
reading for all those intent on moving more
treatment into primary care. The analysis
focused on the amount of growth from
2007/08 to 2008/09 and used the national
Hospital Episode Statistics (HES). Analysis
was carried out on both elective and non-
elective admissions, both separately and
combined. The overall combined headline
figure was an average growth of 6.0 per
cent across England. This compares to an
average of 4.6 per cent across the preceding
three years. Splitting the figures shows a
6.7 per cent growth in electives admissions
and a five per cent growth in non-elective
admissions.
ELECTIVE ADMISSIONS
As far as elective admissions are concerned,
there are a number of reasons why they have
increased faster than emergency admissions.
First is the impact of the 18 week waiting
time target. Figures for November 2009
show that 92.8% of all elective admissions
met the 18 week target. The target has
undoubtedly led to greater levels of activity
as hospitals have attempted to get patients
seen within the target time. Reduced
waiting times themselves had an impact
on activity levels as they reduce threshold
for elective admission. In other words, as
more patients are being seen with shorter
waiting the greater the likelihood that
the newly-diagnosed will be referred. GPs
know the patients they refer will be seen
relatively quickly.
Another factor affecting elective admissions
is patient demand. Patients are becoming
more savvy about their treatment options
and as any GP will tell you, increasing
numbers of patients are turning up to
appointments with print-outs from the
internet. Their expectations play a big part in
elective referrals.
NON-ELECTIVE ADMISSIONS
As for non-elective admissions, the analysis
reveals that growth is nearly all in the
number of patients discharged on the same
day. This is often referred to as ‘zero length
of stay’. This may be happening because of
the A&E target which stipulate that patients
have to be admitted within four hours of
arriving at A&E. This means that patients
who may not necessarily have been admitted
under the previous regime, are finding
themselves admitted for relatively minor
procedures and then discharged the same day.
When looking at the growth in hospital
admissions, you also have to look at the
rest of the healthcare system. For example,
the availability of out-of-hours GP services
plays a role when it comes to emergency
admissions. Continuing disquiet about
GP out-of-hours GP services that surfaced
most recently with national newspaper
headlines following the death of a man in
Cambridgeshire has inevitably had an impact
on expectations. One hospital trust in the
east of England recently pointed the finger
at falling confidence in local out-of-hours
services for its rise experienced in emergency
admissions.
TAKING ACTION
So what can be done to reverse the trend?
The researchers came across several areas
in the UK where referral management
programmes had been successful. The most
successful ones were those that were set up
by local GPs. There is mounting evidence
that these programmes can reduce referrals –
particularly first outpatient referral but less
evidence that they can reduce the number
of procedures carried out. One step that
practices can take to understand referral
patterns is to benchmark themselves against
other practices in the area. This can be done
at speciality level and may be useful to have
when discussing referral management with
the PCT.
Having GPs with specialist interests
will also help to keep referrals down. Well-
integrated GPwSI services are nothing new
but they are still worth considering as part of
referral management.
For non-elective admissions there are two
strands. First is the work that can be done
with patients with long-term conditions such
as asthma. Identifying patients who are at
risk of hospital admission and helping them
to manage their treatment either at home, or
in a primary care setting has been shown to
be effective. One award-winning project of
note is virtual wards in Croydon.
Virtual wards copy the strengths of
hospital wards: the virtual ward team shares
a common set of notes, meets daily, and has
its own ward clerk who can take messages
and coordinate the team. The term ‘virtual’
is used because there is no physical ward
building: patients are cared for in their own
homes. Patients are ‘admitted’ to the award
once they are deemed at high risk of hospital
admission because of a long-term condition.
Second, is a method that stops patients
being admitted at the front door of the
hospital. Very often this involves a GP
triaging patients in A&E. This works because
they have a slightly different approach to
treatment because their first imperative
won’t be to admit.
Whatever you do, you have to understand
the local drivers in the healthcare system
and this means getting to grips with the
statistics. This involves looking beyond
your front door at other practices to see
how you compare. Doing nothing is no
longer an option. The increase in acute care
costs has been restricting the PCT funds
that are available for investment in other
priority areas. Unless the growth in hospital
admissions is addressed, it runs the risk of
taking all growth monies in future years,
and quite likely exceeding them which will
effectively put the local healthy economy
into deficit.
Paul Robinson is head of market intelligence
at CHKS
COMMUNITY CAREDEMENTIA
30 | MAY/JUNE 2012
Working together to tackle dementia
Dementia is costing the UK economy more than £25m per year. Two NHS trusts are doing something about it. COMMISSIONING SUCCESS finds out more
MAY/JUNE 2012 | 31
COMMUNITY CAREDEMENTIA
“In the next 20 years, dementia will become a massive financial concern”
Dementia now affects more than 820,000
people in the UK, a number which is fore-
cast to rise as the population ages.
In fact 163,000 new cases of dementia
occur in England and Wales each year – one
every 3.2 minutes. This is a major issue that
costs the UK economy more than £25m.
Two Merseyside NHS Trusts are taking
a new approach to tackling dementia – cases
of which are expected to rise dramatically
by 2020 – by forming a special network.
Liverpool Community Health NHS Trust
(LCH) and Merseycare NHS Trust are work-
ing together on a ‘clinical network’ which
will pool the resources of both organisations
and will mean that there is a single, clear
pathway which will enable the early iden-
tification and treatment of patients with
mental health needs. Local acute trusts will
also have involvement in the network.
Dave Jones, consultant nurse for older
people for LCH, says: “Dementia is a huge,
growing healthcare issue due to the chang-
ing demographics of the population. It is es-
timated that in the next 20 years, dementia
care will become a massive financial con-
cern, consuming billions of pounds – and
potentially up to half of the NHS budget.
“We need to make sure we are putting
adequate systems and processes in place
to support patients and carers to deal with
dementia. At present on Merseyside there
isn’t a clear single pathway for identifying
and treating dementia patients. So, we are
not really intervening with patients as early
as we’d like. By pooling our knowledge and
resources in this integrated way we can
work more effectively and efficiently.
“People with dementia are present in all
of our care settings – in hospital, interme-
diate care units and care homes as well as
out in the community. We all have some
involvement in identification of patients
and treatment planning , so dementia leads
in both organisations felt strongly that
we should pool our services together and
develop a more integrated approach. This
is simply a new way of working. So for
example, if a patient is recovering following
a hip replacement operation and it is sus-
pected that he or she has dementia, this can
be followed up through use of the network.”
The network currently has identified
three main streams of joint working: a
tailored care and proactive care model, care
home support and the development liaison
psychiatry to support Intermediate Care.
The proactive care model, also known
as tailored care, is a 12-week programme for
patients with long-term conditions. Patients
are identified to take part in this using
health and social care data. This approach
will identify patients with dementia as well
as those suffering other conditions such as
COPD and heart disease.
Jones adds: “With regard to care home
support, what we want is one integrated
care home support team so an LCH nurse
working in a nursing or residential home
could simply call a mental health nurse if
and when necessary rather than having to
refer to mental health teams via GPs.”
He continues: “The third element of
the work, liaison psychiatry, also involves
integrated working. Some patients in hos-
pital beds have dementia and nursing staff
need support with these patients. From 1st
April 2012, there will be further develop-
ments regarding acute hospital liaison
work going on.
“The idea is that Merseycare NHS Trust
has a bespoke liaison team working across
Acute wards. Extending that concept, peo-
ple in the intermediate care system –with
a total of 101 beds –increasingly require
mental health input. It would be great to
have a liaison psychiatry team to help meet
these patients’ needs.”
INFORMATION TECHNOLOGYTOP TIPS
32 | MAY/JUNE 2012
Information for the nation
For commissioning to work, CCGs have to be able to access provider information. Here are our top tips for joining up practice data
PRESENTATIONEncourage practices to present their information so that it will be as easily accessible as possible for the commissioning support officers who will be looking at it. Talk through your plans with the surgeries in your area to ensure they will be working along similar lines and establish a code of practice.
RIGHT TOOLSThe right informatics system is essential if information sharing is to be a success. The ideal system will be simple and easy to use, while being compatible with a wide range of other systems, so that information can be shared across practices using different ones. The right system will enable clinicians across practices to make decisions based on robust and reliable data.
SECURITYThe sensitive nature of patient information, means that secu-rity is of paramount importance. All information should be encrypted and available through password access only. Seek advice from your IT service provider on the best ways to keep information appropriately safe. Backing up all information is particularly important as well, as exposure to other net-works can leave yours more vulnerable to viruses and other security risks. Current trends are leaning towards cloud-based systems, although some still maintain that tape systems offer superior security.
TRAIN STAFF The correct system will only be used to its full potential by staff who are adequately trained and aware of its full capabili-ties. In addition to being able to use the system quickly and efficiently, they should be aware of what to do in the event of data loss or similar emergencies relating to shared informa-tion. Staff should also be educated as to the reasons for shar-ing information and any circumstances in which it should not be granted.
REVIEW If you opt to install a new system across the locality, there are bound to be problems, and the fact that so many other practices are involved, only increases the chances. Stay in touch with the practices’ managers and arrange regular feedback sessions to ensure that ev-eryone involved is gaining maximum value from the process. It is equally important to schedule feedback from staff in order to establish that they are happy with the process and identify any glitches that they are experiencing.
INFORMATION TECHNOLOGYTELEHEALTH
34 | MAY/JUNE 2012
Telehealth has been deemed the solution to giving patients the power to self-manage chronic diseases. So what are the areas it can benefit the
most and how much help has the Government provided commissioners so that they can start implementing it? CARRIE SERVICE investigates
MAY/JUNE 2012 | 35
INFORMATION TECHNOLOGYTELEHEALTH
Early indications from
government research show
that, if used correctly,
telehealth can deliver a
15% reduction in A&E
visits, a 20% reduction in
emergency admissions, a 14% reduction
in elective admissions, a 14% reduction in
bed days and an eight per cent reduction in
tariff costs. The Government also claims it
demonstrates a 45% reduction in mortality
rates. These figures were devised from the
Whole System Demonstrator Programme,
which ran from May 2008 to September 2010.
The study monitored 6,191 patients and 238
GP practices for a minimum of a year across
Cornwall, Kent and Newham assessing how
using telehealth could benefit the NHS. It
aimed to provide “a clear evidence base to
support important investment decisions” and
“show how the technology supports people
to live independently, take control and be
responsible for their own health and care”.
The programme assessed how effective the
use of telehealth and telecare were in treating
chronic diseases; specifically diabetes, heart
failure and COPD.
THE ANSWER TO OUR PRAYERS?
The programme was deemed a great success
by Prime Minister David Cameron: “This
is not just a good healthcare story,” he said,
speaking just after the results had been
published in December 2011. “It’s going
to put us miles ahead of other countries
commercially too as part of our plan to make
our NHS the driver of innovation in UK life
sciences,” he added
John Dyson, chief executive of
Telehealth Solutions, believes the savings
will be vast. Commenting on the headline
findings, he said: “There are enormous
savings to be made from the implementation
of telehealth that could be reinvested in
patient care. We estimate that these savings
could be over £1bn per year which combined
with the improvement in clinical outcomes
demonstrated in the Whole System
Demonstrator results makes the adoption of
this approach a real and pressing necessity.”
And it’s just as well, because Cameron aims
to help three million people with the roll out
of telehealth over the next five years, whilst
simultaneously saving that infamous £20bn
by 2015.
But telehealth isn’t a quick fix, and
should be approached strategically if it is to
really have a positive impact on outcomes
says Mike Evans, commercial director at the
company: “Telehealth will only deliver real
quality to both patients and clinicians if it
is deployed properly to the right patients,
with the right clinical protocols and has the
right supporting technologies and services.”
Knowing your local population and its
specific needs from a commissioning point
of view is key. When trying to implement
a telehealth strategy, usability for patients
should be high on the agenda, after all, it is
they who will be managing it for the most
part. “The technology has to be friendly and
value [has to be] gained through its use,”
says Evans. Allowing patients to be in touch
with their GP and feel ‘in the loop’ with
their progress is a good way of achieving this.
Evans gives the following examples: “The
ability of patients to receive feedback on
their health when they have just completed
a protocol; or engage with their clinician
either through secure video conferencing
or a messaging service; the ability to view
educational videos; schedule hospital or GP
appointments or have motivational/coaching
interviews with a specialist triage nurse. All
of these activities help the patient engage
more strongly, adhere to their care plan,
learn how to manage their condition more
effectively and so derive the best value and
experience from their telehealth system.”
Patients need to feel empowered by the
process, not overwhelmed, in order to truly
engage and have confidence in its aims.
SO, WHAT NOW?
Should commissioners be looking at kick-
starting investment in telehealth? The
Government was very eager to release
figures revealing how much money the
NHS could save through implementation,
and around the time the headline figures
were released, morale around telehealth
in CCGs was high – a GP magazine poll
showed that 83.93% of respondents voted
‘yes’ in response to whether or not they
thought telehealth would benefit patients.
But unfortunately the conversation with
the Government around telehealth seemed
to end once the headline findings had been
released. After an announcement by the
care services minister Paul Burstow in
April this year that telehealthcare could
save the NHS £1.2bn, GP magazine put
in a freedom of information request with
the Government to find out just exactly
how these savings would be made. This
request was blocked, with the department
stating that it could “inhibit future policy
delivery”. Jeremy Nettle from Oracle
Healthcare and chair of Intellect Health
Group, a forum for companies that supply
the NHS, said in his blog on the subject:
“The secrecy around this information does
little to provide the NHS with the faith
that it needs to consider telehealth as a real
alternative to the systems that it currently
has in place. Evidence for how telehealth
can benefit the NHS is limited and the
DH has yet to publish full results from its
Whole System Demonstrator [WSD] trial
of the technology.” He went on to question
whether or not the full implications and
logistical issues for implementing telehealth
had really been considered and suggested
that the Government had come to the
conclusion that telehealth was a success
through looking at evidence that might not
be fully transferable: “It’s likely to be based
on numbers of consultations or potential
hospital savings and some of the small-scale
pilots that have been done. Can we really
scale up these figures?”
It is true that the headline findings of
the WSD were a little vague, and without
specifics it’s difficult to see how the study
will help. If CCGs are to get things moving,
they need more than headline findings and
empty comments; they need information
and evidence.
“Patients need to feel empowered by the process, not overwhelmed, in order to truly engage and have confidence in its aims”
MANAGING COMMISSIONINGLEGAL
36 | MAY/JUNE 2012
Procurement – the facts for GP commissioners
GP commissioners need to understand the ins and outs of procurement better, and many are keen to do so, which is a good thing as commissioning is here to stay. POLLY ELLISON speaks to solicitor RACHEL ROBINSON to find out what commissioning GPs need to know
MAY/JUNE 2012 | 37
MANAGING COMMISSIONINGLEGAL
With commissioning well and truly here, and the threat of reduction to GP income, GPs and their CCGs need to become better acquainted with the rules of procurement. Rachel Robinson, an associate solicitor from leading south west Solicitors, Foot Anstey,
which specialises in healthcare matters, answers some questions on procurement. WHAT IS PUBLIC PROCUREMENT? Organisations (whether government bodies or other public bodies) that spend public money on goods, services and works (like building contracts) must follow strict rules on the process of advertising and awarding those contracts. These rules flow from EU directives and UK legislation – Public Contracts Regulations 2006) (SI 2006/5). The purpose is to ensure that contracts are awarded in fair, non-discriminatory open way. This is known as public procurement.
WHY IS COMPLIANCE NECESSARY AND WHAT HAPPENS IF THE CONTRACTING AUTHORITY DOES NOT COMPLY?Compliance is necessary to limit the risk of challenges to the contract award, damages claims from bidders who have suffered loss as a result of any non-compliance, possible fines as well as adverse publicity and loss of public confidence. Suppliers (or potential suppliers) have a range of legal remedies available to them to keep the procurement process in check: the most significant is that the contract award is declared “ineffective” which usually means that the contract has to be re-awarded, or in some cases the process has to be re-run. Compliance also means that the end result of the authority’s procurement process should achieve value for money, and the best solution available as the right price.
An unsuccessful supplier may obtain further information about the process not previously disclosed by the contracting authority, or challenge the process for non-compliance. Any benefit arising from a challenge should be balanced with the cost of making the challenge and any damage to the relationship with the contracting authority.
DO THE RULES APPLY TO ALL PROCUREMENTS? Contracts with an aggregated value during the contract duration of over specific thresholds generally must comply with the full regime set out in the rules. These thresholds (for non-central government bodies) are:• £156,442 for goods • £156,442 for services• £3,927,260 for works.
Central government contracts are subject to lower thresholds. However, some contracts above these thresholds do not have to follow the full strict rules. Contracts below these thresholds also do not have to follow the full rules, but must follow the general principles (see below).
WHAT ARE ‘PART B’ SERVICES?Certain categories of services are not considered to have as significant European-wide concern as others, and so are exempt
from the full regime (even if are for values above the thresholds). These are known as ‘part B’ services and include legal services, hospitality, health and social care. As such, the procurement of clinical services does not have to be purchased under the full regime. The contract award for these services does, however, need to follow the general principles. These include:• transparency• equal and non-discriminatory treatment of potential bidders• advertising the contract in an appropriate, adequate medium• published clear, specific criteria (and the contract award based
on those criteria)• and sufficient time for prospective tenders to respond to any
invitation to tender.
WHERE CAN I ADVERTISE FOR CLINICAL CARE SERVICE CONTRACTS ADVERTISED?The Department of Health has developed NHS Supply2Health, the mandatory primary care trust (PCT) procurement portal for clinical services providing a single source of information for advertisements where the PCT is the contracting authority.
IS THERE ANY GUIDANCE TO HELP HEALTH PROFESSIONALS?The Department of Health publication, ‘Procurement Guide for Commissioners of NHS funded Services’ applies to CCG’s. Non-compliance may mean a referral to the Cooperation and Competition Panel (CCP) who have the power to investigate any action and make recommendations to the Secretary of State for Health. The CCP’s role is expected to transfer to Monitor under the new healthcare legislation.
WHAT IS ANY QUALIFIED PROVIDER?Any qualified provider (AQP) is a mechanism providing a list of possible accredited suppliers from whom services can be purchased, making the procurement process simpler and less risky for commissioners. This model allows a range of providers to apply without conducting formal tender processes. Providers meeting the accreditation criteria will ordinarily be awarded a standard contract, but there is no commitment to purchase services or supply volume guarantee. The BMA has published guidance entitled ‘What we know so far. Choice and any qualified provider’, which is a useful tool for GPs, but also other health care professionals to get up to speed on this topic.
There is much more to procurement than may, at first, be apparent. Whether GPs are working on CCGs or looking to start up their own provider company, they will have to understand the process. Most of the private provider companies or large NHS Trusts have ‘procurement teams’ that specialise in the tendering process, and who have templates already to ‘drop’ into the appropriate sections of the tender document. This means that these large organisations already have an advantage over their primary care competitors so the sooner GPs learn the ‘ins’ and ‘outs’ of procurement the better.
“Any qualified provider (AQP) is a mechanism providing a list of possible accredited suppliers from whom services can be purchased, making the procurement process simpler and less risky for commissioners”
MANAGING COMMISSIONINGADVICE
38 | MAY/JUNE 2012
Don’t get held backEstablishing a clinically-led organisation without letting bureaucracy get in the way is a challenge CCGs face as PCTs let go. JULIA DENNISON looks at ways commissioners are cutting the red tape
With the Health and Social Care Act, clinical
commissioning groups are choosing
their support from those who know.
Commissioning support units (CSUs) are
emerging like phoenixes from the flames of
winding-down PCTs all over the country,
and many new-found commissioners are taking solace in their
expertise. There is a difference, however, between asking for advice
and running the show, and if GP commissioners don’t take the reins
in full, what is the point? CCGs now have a task on their hands to
commissioning responsibly, while not getting caught in the red tape.
GET THE RIGHT SUPPORT
Philip Jones of Williams Medical Supplies says collaborating with the
people with the right expertise will help ensure successful business
case planning and reduce bureaucracy. “As we enter a new chapter in
the evolution of primary care, clinical demands will be increasingly
weighed against commercial considerations,” he says. ”While facts,
figures, and quantifiable benefits offer nothing new, the level of
detail required is expected to be greater than ever before, as is the
pace at which it is required. Support is at hand for CCGs, not least
by partnering with commercial suppliers who have the expertise and
resources to help.” He also recommends having robust data systems
in place for efficient data management and back office systems can
make a big difference, as can having the right equipment. “Put patients
first with the right equipment and the right support to reduce repeat
visits,” he recommends.
GET GOOD MANAGERS
Karen Watkinson, assistant director of strategy, planning and
assurance, Nottingham North and East Clinical Commissioning
Group says allowing the GPs to commission services requires
good managers. “There is real opportunity, but we do have a fairly
enormous task ahead of us for everybody to get authorised by March
of next year,” she says. “It’s around how those of us within the CCG
work with and for the GPs to negotiate a path for them to make
sure they’re able to do what they need to do. Basically, they’re not
hampered with the bureaucracy; we deal with that
for them.”
Having worked for the PCT, what Watkinson finds
most notable under clinically-led commissioning is seeing the
GPs get involved in the pathway decisions in a real way. “Having the
primary care clinicians in the room with the secondary care clinicians,
so they are each able to put their point of view [forward], we are able to
come to truly clinically-led decisions, as opposed to managers sitting
in the room and fighting out over whose £10 it is,” she says. “The
decisions are being made by the right people and then the managers
are implementing those changes to the best of their ability.”
She believes it is important for clinicians and managers to work
together. “We are all working with a finite budget, so we have to make
those decisions based on ensuring that that budget goes as far as it
possibly can,” she say. “Between us we have to make the decisions
about where that money is spent.”
GET THE PATIENTS INVOLVED BEFORE THEY ARE PATIENTS
Helen Northall, chief executive, Primary Care Commissioning (PCC)
believes there is always less bureaucracy around the well than the
sick, so part of the answer to cut red tape is to start the design of care
pathways at prevention rather than treatment. “That approach goes
hand in hand with self-care, responsible use of services and health
education,” she adds. “All of which will only work, of course, if
patients and the public are fully engaged in the planning and design of
services and aware of the wider issues including the part they can play
in staying well.”
Watkinson has noticed patients being involved much earlier in her
area of Nottingham, even around setting priorities for the CCG. The
commissioning team even holds workshops where they go out into
the public to draw people in and find out what they want out of their
healthcare. “It is interesting, because their priorities do marry up with
the priorities of the CCG,” she adds. “The general feel is we are very
certainly all going in the same direction. By everybody being involved
in that earlier stage, you would hope we would avoid the possibilities
of conflict and it makes the difficult decisions easier because people
can understand why those decisions are made.”