The importance of data in commissioning good care

The emergence of commissioning consortia as the purchasers of most NHS treatment should mean that quality of care is scrutinised more closely than ever before. But from what we have seen so far, it is not a foregone conclusion that this will happen. Indeed, the calls we have taken from consortia representatives reflect considerable uncertainty about what IT tools and data they need if they are to commission good care at the right price.

If consortia are going to be sustainable and effective commissioners, one of the basic things they have to do is ensure they have healthcare IT which lets them make apples with apples comparisons between providers. Unless they manage to do this from the outset it will be immensely difficult to find the huge efficiency savings being demanded of them, without compromising patient services.

The good news is that there are ever more tools out there which allow this to be done. The tough part will be for newly formed consortia, with enormous demands being placed upon them, to be able to identify which IT solutions and what data is of the right quality and value.

The importance of patient pathways

Patient pathways are a case in point. These are normally going to be fundamental to any discussion between purchaser and would-be provider. It may well be that the trust, or other provider, comes up with reams of statistics to illustrate the “typical” pathway. This can be checked using readily available software which, with varying degrees of sophistication, shows that a given trust treated a particular number of patients, and between them they had X outpatient appointments and Y inpatient stays.

There can be a yawning gap between these kinds of simplistic figures and the actual experience of patients being seen by specific consultants. And that gap could reveal that an apparently good system will yield unnecessarily poor outcomes and low levels of patient satisfaction.

To properly understand whether or not a provider’s offering is efficient and effective needs a whole other layer of data to be available. Fortunately it is available, and there are IT solutions which allows consortia to use it in any number of valuable ways.

The key point is that when a consortium looks at the IT options it should choose something which uncovers the very core of what is happening within a system. Seeing data that tells them what happens to the cohort of patients at different stages of the journey is a world away from being able to follow and analyse the set of individual cases through from referral to discharge. And it is the latter that is genuinely illuminating.

A good example comes from cataract treatments, which are generally straightforward and standardised procedures. By looking at something like Map of Medicine it’s possible to see what a best-practice pathway would be – two outpatient appointments in advance, day case surgery and two outpatient follow ups. Naturally there will be variations. However, when we started examining actual patient experience the results were fascinating. One trust had 40 significant variations between the pathways of substantial numbers of patients. We emphasise the “significant” because small anomalies were discounted.

Such a large set of variations looks pretty unusual, but it’s essential to emphasise that we are not saying that because something is atypical it’s necessarily wrong. What we do believe is that purchasers need appropriate evidence at their fingertips to be able to ask the right questions. That means they have to be able to understand differences in case load and mix between trusts, departments and consultants.

Indeed, without that level of detail any attempts at comparisons have to be treated with immense caution. We all recall the concerns when surgical mortality figures started to be published. There were understandable concerns that the surgeons who were the last, best hope for the most frail and sickly patients would be seen as poor performers because relatively, more of their patients died.

Consortia also have to avoid judging by snapshots, and look at performance over a number of years. Fortunately this is possible because there is a full set of records showing patient referrals from across England all the way back to 2006. This is an enormously rich resource for consortia and one they should exploit in every possible way. That can mean looking at what happens at each of the local trusts from which they could viably buy services, but it also enables them to benchmark organisations against their peers elsewhere.

What’s really encouraging is that by using the right technology, consortia can do impressively sophisticated comparisons. They can break down data by HRG, diagnosis, specialism, provider, age and gender. Or they can look at activity such as how often what was supposed to be a day case turned into a longer stay, and the number of excess days there were for inpatient procedures.

And while the NHS has altogether too few quality indicators available, consortia have it within their grasp to understand the performance of any provider by mortality rate and readmission. Once again, it has to be said, this is all about evidence rather than judgements and about providing commissioners with the tools they need in order to arrive at well-informed decisions.

Something that needs to become firmly embedded in the NHS is that actual patient pathways, actual outcomes and actual costs are necessary measures of performance. These, in turn, have to be compared to best practice so variations and exceptions can be understood and inefficiencies eliminated.

Scrutinising spending

These issues are not confined to the care that consortia buy from hospitals. They also apply to the efficiency of the primary care sector itself, and the way it interrelates with the rest of the health service and other agencies. Some £15 billion was spent on emergency care in 2009-10 and we have the means to identify exactly where it went and start to really scrutinise how much is being spent on care. There are huge numbers of patients with diabetes admitted to hospital each year for emergency care – and in many instances better management in the community could have prevented this happening. In other instances it might have been better to divert the patient elsewhere rather than take them into A&E.

Either way, the ability to identify what is happening at practice and consortium level can enable positive change. This may involve closer work with a whole range of stakeholders to develop new approaches to care. If this is something which prevents people having the worry and alarm of a blue light trip to hospital, and saves money, so much the better.

However, while we do feel that well-informed consortia can potentially bring benefits to the NHS, we are worried about the seeming lack of structure in place for the purchase of specialist services. This will often demand that consortia work together, and it seems very unclear at present how such an incredibly important area of commissioning will be carried out.

A further concern, expressed by many in the health service, is that the new structure undermines the tremendous co-operation within the NHS that has often been one of its most admirable features. Can competitors, purchasers and providers collaborate for the common good of patients?

Having the right information can certainly help. In fact, we hope that consortia will see data as providing the opportunity for close collaboration with local providers, rather than simply as a big stick. So if they identify anomalies and raise questions it can give trusts the chance to identify inefficiencies, poor practices and unnecessary costs. Given the chance it seems likely that most organisations will want to re-engineer their systems rather than lose business – bringing benefits for all.

We are well aware of how difficult it is to properly balance quality and cost. We are equally aware that it can only be done with the benefit of good information solutions, and data which enables a genuinely detailed analysis of patient care and costs. If consortia are going to deliver for patients, then the access to reliable and valuable information will be an essential cornerstone of their success.