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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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