Unlock the potential of outcomes based commissioning

In 2012, North Lincolnshire Clinical Commissioning Group adopted the Experience Led Commissioning programme. The programme embodies the principles of outcomes based commissioning in a deeply person centred way. North Lincolnshire CCG applied it to the commissioning of end of life outpatient care for people with long term conditions, dementia and to underpin its major service transformation programme Healthy Lives, Healthy Futures.

‘The NHS is moving rapidly towards outcomes based commissioning. But commissioning for outcomes means starting from a different place’

In November, North Lincolnshire Council also started work to improve outcomes for its weight management services. It has helped the CCG and the local authority to understand what matters to people, families and frontline teams and to develop outcomes frameworks and commissioning intentions based on these insights.

It also implemented a “You Said, We Did” feedback system that helps local people understand the impact they have had on decision making. Some examples are given below:

You said:

• We don’t understand why we need to go to outpatients. We want outpatients to teach us how to manage our conditions better and to connect us with support services and people like us. We don’t want to come to the hospital unless we really need to.
• It is the relationship we have with people within your “system” that keeps us well. We want someone who we trust, who listens and understands our life and who can reassure us when we have an unexpected health issue to deal with. It does not need to be a doctor.
• We as frontline staff struggle to keep well. We find it hard to access GP services and to exercise when we are working shifts. Peer support and the chance to talk to colleagues about our experiences really help us to stay resilient.
• The discharge lounge is an under used asset. We sort out all sorts of practical problems for people − like making sure they have house keys and someone is there to cook them a meal when they get home. It is also easier to pick someone up from here as you can drive to the front door. Everyone who is discharged should come through the discharge lounge.

We did:

• We are commissioning a volunteer led support and “peer connection” service in clinics that directs people to educational information, support groups and events. Providers are redesigning services and communication to ensure the reasons for appointments are clear and that there is a strong focus on education for self care.
• As part of the Healthy Lives, Healthy Futures work, our health and wellbeing board has challenged health and social care partners to consider what a “relationship based” care system might look like and we are taking forward this work as a key part of our integration planning.
• We are working with our acute provider to see how we can increase access to primary care for frontline teams and to use contracting to focus providers on supporting their staff to keep well − and reduce absenteeism and staff turnover.
• We are working with our acute provider to build on this great asset, which we would not have noticed if we had not done this work.

It is clear that changes are not rocket science. Simplifying complexity and defining those small changes is the time consuming, highly skilled part; and this is the place we need to invest and build capability so we can do great outcomes based commissioning work.

The NHS is moving rapidly towards outcomes based commissioning. But commissioning for outcomes means starting from a very different place.

• Analysed: Oxfordshire’s outcomes based commissioning

In the past, we have focused mainly on defining clinical outcomes. We have behaved as if we only have to do the right things to people’s bodies for them to keep well. However, the evidence shows that frontline teams intuitively understand that people’s lived experience impacts significantly on this linear model of health improvement. The things that keep people well and independent are, in fact, varied and often surprisingly simple.

Let providers innovate

Outcomes based commissioning requires commissioners to stand back − and providers to step up to the plate. It requires commissioners to let go and leave providers to innovate. If you are paid on the basis of the outcomes, there is no way around it. You must deliver what matters. As long as outcomes are well formed, this usually requires innovation.

The questions we ask determine the solutions we notice. This is especially true of commissioning questions − often we ask the wrong questions. The current urgent care challenge is a case in point. With winter pressures, the commissioning system continues to ask:

• “How do we reduce the public’s use of accident and emergency?”
• “How do we prevent unplanned hospital admissions for frail older people?”

These questions focus on service use − not outcomes. Meanwhile, outcomes led commissioners who understand what matters to people and families are asking:

• “How do we ensure people feel reassured and confident about managing their unexpected health issues?”
• “How do we facilitate timely access to clinical reassurance?”
• “How do we build resilient support networks around older people so they keep well during the winter months?”

If these were the outcomes we contracted our NHS trusts to deliver, how might it change their focus and behaviour? Would it potentially lead to the design of very different service solutions and different investment decisions?

Behavioural science teaches us that people are generally lazy. They follow the path of least resistance most of the time. This is the basis of “nudge” theory. The same nudge principles apply within commissioning − and most especially in relation to measuring outcomes and holding providers to account for change.

‘Behavioural science teaches us that people are generally lazy. They follow the path of least resistance most of the time’

If you hold organisations to account through satisfaction surveys, tariff payments and process, it is unsurprising that most focus on maintaining satisfaction, increasing volume and “ticking the box”.

If we banned the use of surveys, volume related tariffs and process measures − and instead nudged providers to maintain continuous dialogue with the people who use services and respond with continuous improvements to care and outcomes, it would challenge commissioners to get creative and invent new measurement approaches − and providers to fully engage and understand how services add value for those who use them. But which is the more potent approach?

Purpose maximisation

Relationships trump systems every time. Knowing each other, recognising our shared values and having a sense of common purpose are the “soft and fluffy” bits of commissioning that often get neglected.

Yet, all the evidence shows that the most effective organisations focus on purpose maximisation rather than money. For an engaging overview of the “freaky” evidence base, watch author Dan Pink’s animated lecture (below).

Shared purpose and values are the glue and cement that ensure outcomes based approaches stick and drive integration. Outcomes based commissioners need to unite and align providers behind common values, a shared purpose and vision. This means everyone who affects the person’s care − not just one organisation that is delivering one chunk of it.

New contracting models such as alliance contracting help formalise the process of values alignment. However, whatever contracting model is in place, commissioners play a key role as whole system facilitators who unite providers and communities, build relationships and help everyone to focus on what they have in common − rather than on how different they are.

Georgina Craig is director at Experience Led Care and national programme director for the Experience Led Commissioning programme