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Commissioning for long-term conditions: what do commissioners actually do?
Dr Judith SmithDirector of Policy, Nuffield Trust
The Commissioning Show, Excel, London12 June 2013
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Agenda
• Our study
• What we found about the practice of commissioning
• Implications
• Questions raised
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Our study
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Overview
Aim: To explore the ways in which NHS commissioning can be enacted to assure high quality care for people living with long-term conditions
Timescale: Two years (Mar 2010 – Feb 2012)
Funding: National Institute for Health Research (NIHR) Health Services and Delivery Research programme
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Overview (2)
ApproachBroadly ethnographic, using mixed methods, and with regular feedback to sites
Selection of study sites Quantitative metrics summarising 200 indicators used to identify a cohort ‘high performing’ primary care trusts (PCTs) who were invited to take part
Data collectionObservation of meetings (n=27)Semi-structured interviews (n=124)Informal update interviews (n=20)Analysis of documents (n=345).
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Three commissioning communities
Somerset Calderdale
Diabetes
Stroke Dementia
Wirral
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Commissioning activity being tracked
3 new services which began operating
3 developments being discussed and planned
Somerset - Remodelling of diabetes care into a three tier service
Wirral – Review of diabetic podiatry to resolve operational problems
Somerset – An early supported discharge (ESD) service for patients recovering from a stroke
Calderdale – Review of existing provision of diabetes care and discussion of plans for strategic remodelling
Wirral - Establishment of a new community-based service for diagnosis and treatment of dementia
Calderdale – A strategic review of all dementia care
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What we found out about the practice of commissioning
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1 The practice of commissioning
What we found
•Something much messier, with much more going on;
•Process not happening sequentially;
•Not fitting an annual cycle;
•Co-ordination and facilitation are big parts of commissioning practice;
•Support for implementation also a role for commissioners.
Assumption
A neat cycle of:
• needs assessment• service specification• contracting• monitoring• review
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2 The labour of commissioning
What we found
•A huge amount of time and effort goes into commissioning;
•The scale of effort that goes into commissioning may not relate directly to that of the service;
•Lots of labour is associated with collecting and handling data;
•Decisions about whether to give priority to a commissioning task may be based partly on the resources available to do the work.
Assumption
Commissioning is concerned with incentivising other people to do some work
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3 Identifying the commissioners
What we found
•Multiple and ambiguous roles;
•Providers often involved in commissioning tasks and events;
•Commissioners helping to shape, track and undertake implementation;
•Shared responsibilities across councils and PCTs;
•Clinicians in many different roles.
Assumption
Commissioners are people with money to distribute to meet identified needs
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4 The role of money
What we found
•Money did not seem to be central to a lot of the discussions we observed;
•Money often appeared late on in the story;
•The major decisions appeared often to happen in parallel to the ‘nitty-gritty’ of commissioning.
Assumption
Commissioning decisions will be guided largely by concerns about money
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5 The nature of change
What we found
•Change can be very slow to bring about;
•Commissioners are sensitive about disrupting the local health economy;
•Change often entails moving staff between organisations;
•Easier to bring in something new than to decommission;
•Senior and sustained project management is critical.
Assumption
Commissioning is a mechanism which allows you to make abrupt and radical changes to service provision (de-commissioning and re-commissioning)
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6 National ‘guidance’ in a local context
What we found
•Top-down impetus to get things done – this makes a significant difference;
•A wide range of national strategies and models of what to do;
•Locally set priorities tend to be within this national context;
•Savvy commissioners use the national impetus to press ahead with local work.
Assumption
Local decisions are made by commissioners in response to locally identified needs.
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Implications
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Implications
Commissioning for long-term conditions is made up of multiple and labour-intensive processes
•Some of these align with the commissioning cycle, others do not – some are conspicuous by their absence;
•Commissioning practice is less often focused on whole programmes of funding and service provision;
•It tends to be about more marginal elements of services;
•Decommissioning rarely features.
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Implications (2)
In commissioning care for people with long-term conditions, the relational aspects tend to dominate
•Lots of time and effort goes into service design and specification, stakeholder engagement, planning and convening;
•This work is often critical to bringing about change, but in examples of effective commissioning, there was a recognition of when it was time to ‘get transactional’;
•Questions for the reformed NHS include whether it can afford so much relational commissioning.
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Implications (3)
The cycle of commissioning lends some order and routine to commissioning
•It helps commissioners to tie in with the financial planning cycle, contracting, etc.;
•Long-term conditions are less easily ‘commodified’ than elective services;
•They may require a different approach to risk-sharing and contracting, with providers incentivised across organisations.
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Implications (4)
There are some critical enablers of commissioning practice
•Skilled managers, especially at middle-management level – boundary-spanners;
•Accurate and timely data;
•A judicious amount of meetings and workshops;
•Sustained involvement of clinicians;
•Careful use of national guidance at local level;
•Clarity about the outcomes expected of commissioning;
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Questions raised
1. When it comes to the labour of commissioning, how much is too much?
2. To what extent does the blurring of roles challenge the commissioner/provider split? Does this matter?
3. Should money have a more central and specific role in commissioning conversations?
4. Are commissioners held back by caution, or by constraints? Will GP commissioners be more radical?
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Acknowledgement and disclaimer
This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 08/1806/264).
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HSDR programme or the Department of Health.
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