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Practice-based commissioning: achieving maximum gain

Sharon Willis

Director
Connecting Quality Consultancy Solutions Ltd (CQCS) and Connecting Quality Development Solutions Ltd (CQDS)

A wide range of publications and guidance on practice-based commissioning (PBC) are issued on a regular basis by the Department of Health in England.(1) In this series of CPD articles, the national guidance is not regurgitated but is combined with world class commissioning guidance to provide a practical approach to achieving maximum gain through PBC within a local health economy.(2)

Box 1 (below) displays the core elements of commissioning, taking account of the world class commissioning competencies, and clearly indicates the systematic process at the heart of commissioning healthcare services.(3) It is this systematic process that will be used in this series of CPD articles to support the demonstration of achieving maximum gain through PBC.

[[Box 1 CPD]]

Box 1: the core of commissioning

This first PBC CPD article focuses on the first two elements of the commissioning process set out in Box 1: understanding health and wellbeing needs, and reviewing the health impact of services.

Since 1 April 2008, PCTs, in partnership with local authorities, have been required to a undertake Joint Strategic Needs Assessment (JSNA) to identify the current and future health needs of the population.(4) This joint work does not detract from the localised work that should be undertaken to understand local health and wellbeing needs. However, the JSNA should be used to inform work within local communities.

World class commissioning reinforces that only those services that meet an identified need of the local population and achieve health gain should be commissioned by practice-based commissioners and PCTs. With this in mind, the first step for practice-based commissioners in achieving maximum gain must be to understand the actual and perceived needs of the local population.

Once gathered and understood, this intelligence should then underpin all future commissioning decisions, including: identification of pathways requiring redesign; new services which need to be developed; and services that are to be decommissioned.

The first stage in understanding the health and wellbeing needs of the population is planning. Not the most exciting element of the work but undoubtedly one of the most important elements. Insufficient planning will more than likely have a negative impact on one or more of the stages ahead and may affect the validity of the intelligence gathered.

The planning stage should start with identifying and agreeing the actual population to be included in this activity. This may be restricted to the population served by the practice-based commissioners or the wider population served by the PCT.

Setting out what is to be achieved, how you are going to achieve it and over what timescale is an essential first step. Think about  who needs to be involved in helping you achieve your goal and be realistic about the resources, both human and financial, that you will need access to in order to deliver this work. A further critical success factor is the identification of any barriers that you think you may encounter and proposals detailing how you propose to overcome these.

During the planning stage, you should think about the contribution of community partners; clinicians and of course the population. Take time to identify whom you need to involve and what you anticipate their contribution to be. A good way of identifying who you should be involving is to first think about who will be affected by your work now or in the future.

When undertaking this activity, take time to ensure that you consider the direct and indirect impact of your work. Also think about the level of involvement that each individual or group will need at each stage of your work. For example, do they need to be consulted with at a particular stage or do they need to be kept informed of the work being undertaken?

Once you have identified those that need to be involved in your work, think about the best way to involve the identified individuals and groups, and also think about the most appropriate way to communicate with each individual and group. Record this information in a communication plan rather than keeping it in your head. This will ensure that others around you have access to your thinking and can also make valuable contributions.

Once you have thoroughly planned your work and written up your proposal, it is essential that the relevant individuals and organisations endorse the work to be undertaken. This may include other practice-based commissioners and of course includes the PCT. Spending time securing the endorsement of others will help prevent misunderstandings from occurring further through the process which may delay your work or even bring it to a complete halt.

Once you have your written proposal and secured the endorsement of appropriate others you are ready to implement your plan and move to stage two and start gathering intelligence about actual and perceived health and wellbeing needs.

The first action of gathering intelligence is to profile the identified population. Getting a good map setting out the geographical boundaries is always a good place to start. You can then start drawing in information such as population density as well as ethnicity and age distribution. You may also find it useful to mark where current local services are located, such as GP practices, community health centres, local hospitals and schools.

The public health team within your local PCT will be able to supply you with intelligence to demonstrate a range of mortality and morbidity statistics, but don't forget to take a look at the intelligence available from your local health observatory and from the Association of Public Health Observatories.

Once you have gathered, analysed and recorded all of the intelligence available, you are now ready to test your interpretation with the local community, community partners and clinicians. This is an important step in enabling you test out whether your profile reflects the community that your local population, community partners and clinicians live and work in.

This process of testing your profile may also enable you to gather further intelligence to further strengthen your profile. Don't forget to refer back to your communication plan to remind you whom you need to test your profile with and the most appropriate way to do this.

While engaging with the local population, community partners and clinicians, you should also be gathering intelligence about their perception of the health and wellbeing needs within the population and their perceptions about the factors that directly or indirectly impact upon local health and wellbeing needs.

The next stage in understanding health and wellbeing needs is to identify and agree the health priorities for the population.

With those that live within the community and healthcare professionals that work within the local community, you now need to identify the healthcare condition and factors influencing these conditions that are having the greatest impact on the local population.

To help you identify the priority order for these conditions and factors, try to identify the severity of impact and the size of the population affected. At this stage it is also helpful to identify potential solutions and consider the time that will be taken to implement these solutions.

When agreeing health priorities, don't forget that there is a requirement for commissioners to achieve a range of health priorities each year. You will find these detailed in the NHS Operating Framework currently published annually by the Department of Health.(5)

Further detailed information to guide you through the process of understanding the health and wellbeing needs of a population can be found at the National Institute for Health and Clinical Excellence (NICE) website.

Before moving on to any detailed planning of changes that you think is needed, it is essential to review the health and wellbeing impact of current services. This will ensure that you have sufficient intelligence to inform investment priorities for the future. Don't forget to write up the intelligence you have gained about the health and wellbeing of the population, along with their health needs and health priorities, before moving onto the second element of the commissioning process.

Health impact assessments are increasing being undertaken across the NHS when local and national healthcare leaders are developing new health policies and strategies. Probably the most frequently used impact assessment is the equality impact assessment, due to the fact that all public bodies have a legal duty to promote equality and eliminate discrimination. Further information on equality impact assessments in the NHS can be found at the DH website.

If practice-based commissioners and PCTs are going to achieve one of the goals of world class commissioning and ensure that all commissioned services are underpinned by health needs and deliver health gain, it is essential to determine the impact of services currently being commissioned.

When undertaking an impact assessment of currently commissioned services, it is important to focus on collecting the right information and not get detracted by the wealth of information that may be available.

The first step in your impact assessment of currently commissioned services is to identify which service you are going to start with. This will probably be influenced by your health priorities.

Once you have identified the service you wish to assess, you need to access a range of intelligence that will be held by the PCT. First, you will need the service description. This description usually sets out on overview of the service, including how the service will be delivered and who is able to access the service.

You also need to understand the agreed aims and outcomes for the service and the performance measures for the service. All of this information, along with the costs of the service, should be located in the service specification held by the contracts team within the PCT.

Additional information that you will need includes confirmation of how well the service is doing in achieving the agreed outcomes and performance measures, who is actually accessing the service and how does this compare with who can access the service, and a comparison of actual activity versus commissioned activity. All of this information should be readily available from the contract monitoring team at your PCT.

Once you have gathered the range of information set out above, you are ready to start your analysis and determine the impact that this service is having on the health of the local population and its effectiveness in achieving health gain. Don't forget to refer back to your communications plan at this stage and ensure that you involve the identified individuals and groups in your analysis. This may include representatives of the local population, community partners, clinicians and may include the current service provider.

In undertaking your analysis, make sure that you reference back to your health priorities to test the effectiveness of the service. For example, a health priority may be for 60% of the identified population to have stopped smoking within two years. In this instance, your analysis needs to determine the impact of the current smoking cessation service so as you can determine whether this service will sufficiently meet the health need and deliver the required gain in a cost-efficient manner.

You should conclude this stage of your work by testing your findings with the local community, community partners and clinicians to determine whether the information gathered reflects the service from the perspective of others. Finally, you should write up your findings and share these with those involved.

Having identified the impact of services currently commissioned, you are ready to move onto stage three of the commissioning process – determining investment priorities. This next stage will be covered in PBC CPD article 2.

References
1. Department of Health. Practice based commissioning: clinicians in commissioning [internet homepage] Available from: http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Practice-...
2. Department of Health. World class commissioning [internet homepage]. Available from: http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Worldclas...
3. Willis S. Using world class commissioning to strengthen practice-based commissioning. National Association of Primary Care Summer 2008;45-6.
4. Department of Health. Joint Strategic Needs Assessment [internet homepage]. Available from: http://www.dh.gov.uk/en/Managingyourorganisation/JointStrategicNeedsAsse...
5. Department of Health. The Operating Framework for 2009/10 for the NHS in England. London: DH; 2008.

Resource
Further information about health impact assessments can be found here.