PCTs make a good shot at prioritisation

Analysis of primary care trusts’ commissioning priorities - shared exclusively with HSJ - suggests the organisations are improving health based on local needs. The work, by public affairs consultancy Health Mandate, adds to evidence that PCT commissioning is contributing to improving services and health outcomes.

As commissioning is set to be overhauled by the government, the analysis also highlights some of the risks associated with passing it to groups of GPs.

Priority setting is seen as fundamental to improving population health through commissioning. The Department of Health 2007 document setting out the intent behind world class commissioning said: “PCTs should state what their vision is locally, and what they will achieve through continually commissioning better services and delivering better outcomes based on local priorities.”

Prioritisation

PCTs were instructed to name eight priorities each year. Health Mandate looked at four issues commonly picked in 2008 and compared the performance of those that prioritised the issue with those that did not.

Those who named smoking cessation as a priority saw a 1.4 per cent increase in numbers giving up between 2007-08 and 2008-09, compared with a 6 per cent decrease among those who did not make it a priority. For breast screening coverage, those who prioritised saw a 7 per cent increase and those who did not only 0.3 per cent. The findings were repeated in other areas [see box].

Health Mandate found most commissioners picked priorities where their performance was below the national average, although a third picked areas where they were above average.

The report identifies variation in improvement between PCTs, and problems with PCTs applying their priorities consistently, for example in their pay by performance contracts with providers. But overall PCTs have been able to “effectively identify and prioritise the issues which matter most to their local community”.

Health Mandate believes it has found some evidence that prioritisation, as well as improving performance and quality, increased efficiency and productivity, with PCT spending rising more slowly on areas which were prioritised.

For example, the average spending increase on cancer and tumours between 2007-08 and 2008-09 was 7.1 per cent for PCTs which had selected a relevant indicator as a priority and  8.8 per cent for PCTs which had not. For endocrine, nutritional and metabolic disorders the increase was 11.8 per cent where prioritised and 12.5 per cent where not.

The report’s authors comment: “In the context of the current financial climate this is encouraging and reaffirms the importance of appropriate prioritisation.”

Health Mandate found service and disease areas chosen by PCTs “broadly reflected national priorities”. Notable prioritisation successes in recent years have included hospital waiting times, access to GPs, cardiac and cancer care, and smoking cessation. At present, performance management and accountability of PCTs has been clear and direct largely because of targets - there are 64 vital signs in the 2010-11 operating framework - and the power of regional and national NHS management to put pressure on and replace board members.

Criticism

Health secretary Andrew Lansley has criticised “top-down” management and “clinically unjustified” targets, suggesting these levers will not be available. That said, the white paper consultation suggests the national commissioning board will have some power over consortia, and says the board itself will design the assurance process. The proposals also say process measures - along with outcomes and structures - are legitimate measures for accountability on quality.

The NHS Confederation’s discussion paper on the reforms expresses concern that the NHS commissioning board - which will run performance management and accountability - will have to deliver improvements “without directly performance managing consortia against specific priorities and requirements”.

Jeremy Taylor, chief executive of National Voices, the umbrella group for patient organisations, also told HSJ it was unclear what mechanisms would be used for improvement in the future.

He says: “If performance management is out, the question will be, ‘who will form a national picture of things that need to be done, and ensure they get done?’

“Healthcare has local, regional and national dimensions to it. Just because you create an architecture with emphasis on devolution you can’t escape the fact there is a national dimension,” he says.

Accountability

Health Mandate recommends all commissioners be required to “identify priorities and account for their performance against them”. It calls for the DH to create an “interim performance management programme for commissioners” to “support both local and national accountability” as GP consortia take over responsibility.

There is also concern the significant limits expected to be put on management costs will stand in the way of identifying and acting on priorities, and figures being discussed by the DH are about a third of the £1.5bn PCT and strategic health authority management spend in 2008-09.

Phil Da Silva, a former commissioning director who is working on clinical commissioning for the DH’s quality, innovation, productivity and prevention programme (QIPP), says GPs would improve on PCT commissioning and respond well to accountability, but support was important.

He told HSJ: “Accountability with responsibility is where we are taking GPs, and most will react and work to that.

“They will be looking for support to prioritise, make service improvements and improve value. The support, and incentives, have to be right.”

World class commissioning - a process driven assurance programme - was created to measure and improve PCTs’ capability, and from the little evidence available appears to have started working. It looks likely there will be no similar programme for consortia, in favour of focusing on their performance and outcomes.

Further analysis of Health Mandate’s research data by HSJ suggests PCTs scoring well on commissioning processes as measured by the world class programme have been more successful in improving service.

The top 10 rated PCTs perform better, on average, than the worst 10 on three out of four measures examined.

But the link was not visible across all PCTs.

Health Mandate concluded attempts to manage commissioners without looking at processes will be complicated by lack of useful performance and outcomes data.

It found: “Accountability for commissioning performance is hindered by inconsistencies in data availability.” Information is also too often delayed to be useful, the report says.

Several priorities analysed by Health Mandate relied heavily on public health work, such as smoking cessation, or coordinated improvement in public health and NHS services, like cancer mortality.

The government is separating these responsibilities by passing public health to local authorities.

The report proposes the DH issues national strategies for improvement, led by national clinical directors and covering NHS GP consortia, the public health service, and social care.

It says: “It will be important that prioritisation is coordinated otherwise effective service delivery will be compromised.”

Coordination

But Health Mandate argues there is a risk that coordination will not happen. Even in the “top

-down” system, coordination is often missing, particularly between performance managers and regulators.

Health Mandate found the Care Quality Commission’s measures for judging PCTs generally did not match priorities used in performance management and world class commissioning.

There should be closer alignment, the report says.

But the authors argue the government would be wrong to strip the CQC - as proposed - of responsibility for commissioners, and place both performance management and regulation with the national board.

The report says this would mean there was “no formal regulatory process for assuring the quality of outcomes achieved by commissioners, as opposed to their financial health”.

National Voices’ Jeremy Taylor says: “At a local level we need effective and responsive NHS organisations… we also need mechanisms for ensuring things can be driven beyond local level.

“The role of bodies like the CQC will become very important to ensure emerging problems are picked up, and that somebody does something about them.” l