Written evidence from the Health Foundation
(COM 78)
1. ABOUT THE
HEALTH FOUNDATION
1.1 The Health Foundation is an independent
charity working to continuously improve the quality of healthcare
in the UK.
1.2 We want the UK to have healthcare systems
of the highest possible quality—safe, effective, person-centred,
timely, efficient and equitable. We believe that in order to achieve
this, health services need to continually improve the way they
work.
1.3 We are here to inspire and create the
space for people to make lasting improvements to health services.
Working at every level of the system, we aim to develop the technical
skills, leadership, capacity and knowledge, and build the will
for change, to secure lasting improvements to healthcare.
1.4 The Health Foundation submitted evidence
to the Health Committee's recent inquiry into commissioning.1
We would be pleased to give oral evidence to the Health Committee
so that members can speak directly to experts who have developed
these insights.
2. EXECUTIVE
SUMMARY
2.1 Health Foundation research has shown
that commissioning led by primary care can have a beneficial impact
on primary and intermediate services through improved responsiveness
and innovative working practices. However, primary care led commissioning
has had less impact on hospital provision.
2.2 Commissioning has struggled in the past
to engage patients effectively. The Health Foundation has pioneered
a new process for engaging local communities in setting commissioning
priorities and making disinvestment decisions.
2.3 The transfer of commissioning responsibilities
must include clear lines of authority and accountability. Peer
review across consortia could provide a mechanism for avoiding
the potential conflicts of interest if GP consortia are to performance
manage GP practices. Care must also be taken to avoid local services
being managed too remotely.
2.4 Primary care led commissioning will
only be effective if significant levels of management support
are provided, including investment in developing new skills.
2.5 The new NHS Commissioning Board must
take the in lead inspiring and communicating best practice in
patient safety and develop mechanisms to encourage quality improvement
and engagement so that advances in these areas are maintained
during the transition to the new arrangements.
3. EVIDENCE AND
LEARNING FROM
THE HEALTH
FOUNDATION CONCERNING
COMMISSIONING
Commissioning in the wider context of the White
Paper
3.1 We welcome the Government's focus on
putting the patient at the centre of health services. To realise
its vision, evidence shows we need to focus on changing relationships
between people and services, inspire improvement through clinicians
and transform organisational approaches to patient safety. The
proposals for a National Commissioning Board and GP commissioning
have profound implications for the health service. It is important
that the best available evidence informs preparations for these
changes.
The Health Foundation's research on commissioning
3.2 The Health Foundation has commissioned
extensive in-depth research to examine the available evidence
on commissioning. This has led to:
— a clear understanding of what can and
cannot be achieved by commissioning;
— knowledge of the essential prerequisites
for successful commissioning;
— development of a systematic approach
to community engagement that produces fair, transparent, evidence-based
decisions on commissioning priorities and disinvestment; and
— insights into the impact of commissioning
on costs and efficiency.
3.3 We have focused this submission on evidence
from our research—published and unpublished.
Our key findings on the limits and potential of
primary care led commissioning
3.4 In 2004, the Health Foundation commissioned
a review of the evidence on the effectiveness of primary care
led commissioning.2 This research has withstood the test of time
and is highly relevant to the White Paper's proposals. It clarifies
what can be achieved through effective commissioning; which outcomes
are beyond the influence of commissioners; and the essential prerequisites
for successful commissioning. Primary care led commissioning can:
— secure improved responsiveness from hospitals
such as shorter waiting times for treatment and more information
on patients' progress;
— make its greatest impact in primary and
intermediate care, eg in developing new practice-based services,
stimulating new forms of peer review and quality assessment, enabling
new forms of specialist primary care, and building new community-based
alternatives to hospital care;
— where managers show high degrees of determination
this can enable innovations that change longstanding working practices;
— effect change in prescribing practice,
with financial incentives playing a key role, as demonstrated
through GP commissioning and fundholding;
— the Health Foundation's 2004 report found
little substantial evidence to show any commissioning approach
has made a significant or strategic impact on secondary care services,
except in relation to very specific indicators such as waiting
times; and
— the report further showed that primary
care led commissioners have struggled to engage patients and the
public in any significant way.
Essential elements for successful commissioning
3.5 This research found a number of replicable
characteristics of successful primary care led commissioning,
including:
— different population bases are needed
for commissioning different services—there is no single
"ideal" size for commissioning organisations;
— adequate levels of management support
are vital, and schemes with higher levels of support tend to produce
better outcomes;
— timely and accurate information is required
for effective commissioning;
— real clinical engagement is crucial;
— there is a balance to be struck between
clinical engagement and appropriate public and management accountability;
— as well as maintaining effective strategic
relationships, commissioners need to be able to shift activity
to different providers;
— commissioning organisations need a degree
of stability in the wider policy context; and
— new and more advanced forms of support
are required such as the stratification of patients according
to risk, commissioner-led advanced case management and predictive
modelling of high-intensity service users.
Engaging communities in commissioning priorities
and disinvestment decisions
3.6 Informed by the 2004 review, the Health
Foundation commissioned a project on the Isle of Wight3 to engage
health partners and local communities in the process of developing
commissioning priorities. This work set out to achieve a shared
understanding of the issues and sense of common purpose, while
preserving differences of opinion and allowing for differences
in the individual paths taken.
3.7 This systematic process for engaging
health partners developed approaches that would:
— provide an audit trail;
— empower senior managers to justify difficult
decisions based on relevant evidence;
— enable decisions that take account of
the greatest potential impact on the health of the population;
and
— engage the local community.
3.8 The process achieved this through:
— continuous engagement with the public
and patients to shape services and improve health following techniques
developed by Professor Gwyn Bevan of the London School of Economics;
— partner workshops to identify and assess
the cost and value of different initiatives to improve population
health and quality of life; and
— multi-criteria scoring, including the
numbers of people who would benefit, "visualisation"
of beneficiaries and the scale of individual health benefits.
3.9 The process resulted in a clear set
of health priorities with specific recommendations for reallocating
resources.
3.10 Following the success of this initiative,
further research is now underway with NHS Sheffield to develop
these processes further to inform disinvestment decisions. It
is of course absolutely critical that the NHS manages disinvestment
effectively and fairly so that it can make the most of efficacious
innovations while phasing out legacy, less productive services.
The research at NHS Sheffield is developing clear methods to make
fair comparisons between different treatments and services in
terms of their impact on health outcomes.
3.11 The Health Foundation's work in the
Isle of Wight and Sheffield shows how systematic engagement can
be achieved by commissioners to ensure fair, justifiable decisions
that lead to the greatest potential impact on the health of the
population.
Commissioning for outcomes and the impact on efficiency
3.12 The 2004 evidence review suggests that
primary care led commissioning increases transaction costs.
3.13 Evidence also suggests that effective
commissioning for outcomes can have varied and unexpected effects
on efficiency. Recent research4 by the Health Foundation shows:
— throwing money at a problem will not
necessarily fix it: efficiency is strongly negatively correlated
with allocations in excess of targets. What this means in practice
is that there are diminishing marginal returns on health expenditure.
Overall efficiency is likely to drop as additional funds become
available;
— PCTs with higher levels of deprivation
tend to be less efficient; and
— achievement on some Quality and Outcomes
Framework indicators, for example chronic obstructive pulmonary
disease, correlates with efficiency levels. Other indicators including
those that relate to diabetes and coronary heart disease show
a negative correlation. This may be because achievement in these
domains takes time to show through in improved mortality. This
suggests that perversely, improving health outcomes does not always
lead to more efficient health costs.
4. ANSWERS TO
QUESTIONS POSED
BY THE
COMMITTEE
Clinical engagement in commissioning
4.1 Clear lines of accountability and authority
to manage poor performance across local health economies are vital.
This includes power for commissioners to ensure all elements of
the local health community act coherently. Ultimate responsibility
needs to rest with lead commissioners, which under the proposals
in the White Paper means GP consortia.
4.2 The White Paper is ambiguous in relation
to ultimate responsibility for driving up the quality of primary
medical care. On the one hand it is the NHS Commissioning Board
(NCB) that commissions practices but on the other hand consortia
may well carry out on its behalf some aspects of this work. The
Health Foundation urges clarity of role and responsibility in
relation to this matter and suggests that although it may take
time for consortia to develop the appropriate skills to carry
out these responsibilities this is where they should ultimately
lie.
4.3 Peer review processes could be developed
across consortia as a mechanism to avoid conflicts of interest.
The Health Foundation's 2004 review of evidence described in paragraphs
3.5 to 3.11 identified new forms of peer review as one of the
innovative and successful approaches arising from primary care
led commissioning.
4.4 Given the findings of the 2004 research
set out at paragraph 3.5, there does not appear to be any logic
in placing commissioning responsibilities for maternity services
with the NCB. As an essentially local service, this should be
with GP consortia.
4.5 The 2004 research also identified the
need for new and more advanced forms of support such as the stratification
of patients according to risk, commissioner-led advanced case
management and predictive modelling of high-intensity service
users. While the World Class Commissioning initiative has made
some progress here, it is important that this progress is not
lost through the transition to the new arrangements and that consortia
are suitably supported.
How open will the system be to new entrants?
4.6 As we have set out above, there are
a number of replicable characteristics of successful primary care
led commissioning that are particularly relevant to the reforms
proposed in the White Paper:
— Different population bases are needed
for commissioning different services—there is no single
"ideal" size for commissioning organisations. The proposals
give consortia significant local flexibility to respond to local
population need, but it is not clear what, if any mechanisms will
assure the process of matching consortia size to the services
they commission. Also, it may be that smaller consortia are able
to commission appropriately for some services, but they will need
to find mechanisms to work together to commission other services
across a larger population base.
— Research shows that adequate levels of
management support are vital, and schemes with higher levels of
support tend to be more effective in terms of outcomes. In the
context of a significant decrease in the level of overall NHS
management capacity it will be particularly important to ensure
that GP consortia have access to sufficient levels of support.
— In an environment where competition in
healthcare is being encouraged commissioners will need to employ
methods such as those developed in the Isle of Wight and Sheffield
to balance the tension between ensuring clinical engagement and
assuring appropriate public and management accountability.
Accountability for commissioning decisions
How will patients make their voice heard or their
choice effective?
4.7 The Health Foundation's work in the
Isle of Wight and Sheffield, as set out in paragraphs 3.5 to 3.11
above, shows how the full spectrum of community partners can be
engaged effectively in making decisions about local commissioning
priorities and disinvestment.
4.8. The Health Foundation's Co-creating Health
initiative5 shows that significant improvements in health outcomes
can be achieved if patients become "activated"—ie
they become active partners managing their health. This includes,
but goes significantly beyond, simple choice of provider of care
or commissioner. By engaging activated patients, GP commissioners
will need to consider different forms of provision that support
active self-management. This is a distinctly new and separate
dimension of the choice/voice debate.
What will be the role of the Commissioning Board?
4.9 It is particularly important during
the period of transition and major structural change that there
is clear leadership from the centre to encourage, inspire and
communicate best practice on patient safety and continuous improvement.
This includes building appropriate technical expertise on the
new Commissioning Board and ensuring alignment of roles and action
by the Commissioning Board, Monitor, the CQC and NICE.
How will commissioning interface with the Public
Health Service?
4.10 A potential unintended consequence
of the creation of a national Public Health Service, should it
be given responsibility for commissioning school nurses and health
visiting services, would be to add to the number of bodies responsible
for different elements of health services for a given population.
In an context where the Public Health Service, a GP consortium
and the NCB will all have a commissioning role to play, and at
a time when there will be tough spending decisions to be made,
it is vital that one player—in our view the GP consortium—should
be given an overall, formal co-ordinating function.
Where will the "buck stop" when commissioners
face hard choices?
4.11 The Health Foundation strongly believes
that the GP consortia should take responsibility for their decisions.
Clear lines of accountability are essential prerequisites for
successful commissioning. Consortia must develop the resilience
to justify often controversial decisions to reconfigure services
based on the best available evidence, local community and clinical
need. This includes confidence that the NCB will not second-guess
local decision making as a result of political considerations
or media pressure.
Integration of health and social care
4.12 Forthcoming Health Foundation research,
Does Care Coordination Improve Quality and Save or Make Money?
By Dr John Øvretveit, indicates that poor coordination
absorbs approximately 5% of healthcare costs. The NHS must be
able to achieve these savings under the new arrangements and during
the transition period.
How will the new arrangements strengthen commissioners
against provider interests?
How will vulnerable groups of patients be provided
for under this system?
How will the proposed system facilitate service
reconfiguration?
4.13 The Isle of Wight/Sheffield evidence
detailed in paragraphs 3.5 to 3.11 above demonstrates the importance
of consortia-led systematic engagement to set priorities and facilitate
service reconfiguration. By engaging all stakeholder groups and
focusing on evidence and overall public health outcomes, fair
decisions become possible that transcend provider interests and
protect vulnerable groups of patients whose voice might otherwise
not be heard.
4.14 Preliminary statistical analysis by
the Health Foundation earlier this year5 showed that PCTs with
higher levels of deprivation tend to be less efficient. The new
arrangements need to take this into account to avoid replicating
structural weaknesses.
ENDNOTES1 The
Health Foundation submitted written evidence to the Committee
in September 2009. The submission can be found in full at: http://www.health.org.uk/publications/consultation_responses/evidence_to_inquiry.html
2 Smith J, Mays N, Dixon J et al (October 2004).
A review of the effectiveness of primary care-led commissioning
and its place in the NHS. Health Foundation.
3 The Health Foundation (2010). Improvement
in practice: Commissioning with the community.
4 Martin S and Smith P (2010). Commissioning
health. A comparison of English PCTs: preliminary statistical
analysis. London: Health Foundation.
5 Co-creating Health is a self-management scheme
that aims to transform healthcare for people with long-term conditions.
Weblink: http://www.health.org.uk/current_work/programmes/cocreating_health.html
October 2010
| 
