The development of commissioning in UK healthcare has been a long time coming, to put it mildly. Although the NHS reforms often paid lip service to the idea (strengthening the commissioning function was a stated goal of creating PCTs), much action up to 2004 focused heavily on the supply side, with waiting list targets, star ratings and foundation status for acute trusts.
Attention has now switched to the demand side of healthcare, which means that commissioning is back centre-stage. The 2008-9 Operating Framework, the Darzi Review and the Department of Health's informatics review all underline the vital role of good-quality and timely information as the bedrock on which commissioning must be built.
Driving up quality
The NHS Information Centre chief executive Tim Straughan is emphatic that his organisation's strategy puts heavy emphasis on information to support care quality improvements, and specifically, to support commissioning. "In my view commissioning is probably the most powerful lever we have to drive up quality in the NHS," he says.
Mr Straughan outlines the three broad fields of commissioning information needs:
the current status of population health
information about future population health needs
information about the services commissioners are getting from provider functions (be they NHS acute or foundation trust, or independent and third sector), and how these perform and compare in care quality and patient satisfaction.
He adds: "It's fair to say that current information servicing these three is patchy, and doesn't make best use of the data that is already available. There are big gaps we need to fill, and there's a key role for The NHS IC to help fill them."
Where does Mr Straughan see missed opportunities to make best use of current data? "To assess current and future health needs, there's good information available from public health observatories and sources like our own Compendium of Clinical and Health Indicators. I don't think these resources are widely enough used in commissioning," he says.
"Programme budgeting is another area - a really good Department of Health initiative, with lots of information about different specialities. Commissioners could be making better use of it to examine where they're spending their money and how they compare with other peer organisations."
Mr Straughan highlights The NHS IC's NHS Comparators product as another very powerful source of information for PCT or practice-based commissioning consortia commissioners, based on hospital episode statistics data. "While it gets good use and take-up, it can be much more fully used," he says. "There are also some effective support tools provided by the private sector, including our joint venture partner Doctor Foster Intelligence, which probably aren't used as effectively as possible.
"Perhaps commissioners don't know about these resources, which means a signposting job for us. Or perhaps they know they're there but lack the capacity to use them - which links to Competency Five of world-class commissioning - to manage knowledge and asset needs."
Climbing the data mountain
Sandra Hills, the NHS IC's director of commissioning, believes that NHS managers understand the relationship between data use and commissioning in ensuring decisions are robust. However, she says: "I'm not sure they understand if they analyse different types of information, how the different pieces can be used, and how to discern between them in relationship to commissioning differently."
She also emphasises the sheer amount of information is a challenge for commissioners. "The NHS IC has a colossal amount of different data collections and sources," she says. "Commissioners must understand which of these are most helpful to develop commissioning a particular strategy. For more specific services, they're often over-faced with data and find it hard to sift and identify what's most helpful."
She reiterates Mr Straughan's point about The NHS IC's signposting work to put data into formats that are easier to handle and understand. The NHS IC collects or has access to ample data on population size and demographics, lifestyle surveys on behaviours, and basic information on PCTs' coverage, from which public health profiles and condition prevalence information can be derived.
From this, Ms Hills adds: "HES data or SUS data will tell you about acute activity and you can drill down to identify the biggest use of a service or resource. This tells you what you're commissioning; but equally where you might need to rethink services if you're spending on lots of activity but maybe not impacting in health gain or output if mortality or morbidity rates remain high for these conditions."
Ms Hills adds that data from the GP contract's quality and outcomes framework and the national Quality Management and Analysis System also show what is happening in primary care. This informs commissioners about the quality of GP services in the particular conditions measured in QOF.
She concludes: "The NHS IC seeks to be a world-class organisation in collecting, handling and securing data - and presenting it to commissioners in a way that's effective to support and enable them to do a good job."
Mainstreaming quality and outcomes
Brian Derry, programme director for The NHS IC notes that the emphasis on quality and outcomes in both the Darzi Review and the 2008-9 Operating Framework's introduction of patient-reported outcome measures explicitly links improving information with improving commissioning.
"One limit on outcomes is the range of information in NHS data standards and modelling," he says. "Traditionally, there's not been much in outcome measures. We've lots on activity, and mortality rates, but more useful measures are hard to come by.
"Some trusts have their own measurements locally, but understanding relative performance and room for improvement is key. The NHS IC can help define, collect and share a standard data set - and mechanisms to help people use it wisely. Measuring quality and outcomes is a long, hard road, but it's the direction of travel and The NHS IC can help the journey a great deal."
A common complaint is that GP practice-based commissioning consortia find PCT data is less than accurate and less than timely. Can The NHS IC help with this? Mr Derry believes they can help with speed of dissemination.
But, he says: "I suspect it's not just about speed and quality - another dimension of data quality is relevance. Commissioning is increasingly about redesigning services and pathways, to use information to see what we do now, and what we could re-do better as opposed to more traditional contract monitoring. In a world-class commissioning world, waiting until next week rather than today for data should not be critical - but having the right data will be critical.
"The NHS IC wants to measure the right things correctly. It remains challenging to link information between different providers in the acute sector, let alone with those in primary and community care. In the era of choice and plurality, information is still largely about activity and the administration of care in hospitals."
Commissioning is, of course, not confined to health. Social care has been more actively commissioned (and of course means-tested) by local authorities for two decades, and since many 'heavy users' of one may also be big consumers of the other, the synergies are clear.
Robert Lake, The NHS IC's director of social care, observes that local authorities have been good at picking up information on demand for social care, and on the nature of their own performance and population needs. According to Mr Lake, they have been able to feed that information through into commissioning.
He said: "PCTs have struggled with performance information. It's such a massive area with trying to handle key bits of information to show where people move between primary and secondary care, let alone within each. The NHS IC can start to identify for PCTs or PBC consortia the key information they need to do commissioning properly. We're looking at how to bring together social care and NHS data for joint strategic needs assessments and to contribute to local area agreements."
Mr Lake adds that the new national indicators set from the Department for Communities and Local Government will dramatically change the whole nature of information for social care. "Under the new national indicators set, only eight of 198 categories relate directly to adult social care, where there used to be around 500," he says.
He believes that to achieve world-class commissioning, eight social care indicators will give too flat a picture. "So for added depth, we're organising voluntary data collections with local authorities to fill the gaps, and we'll marry that with NHS data," he adds.
Mr Lake also stresses that better integration of social care data with health data is vital to 'future-proof' commissioning. "Social care information will be a good indicator of future issues for health," he says. "For example, we can anticipate that users of domiciliary care, who aren't getting NHS services now, will need district nursing in future. Anticipating demand means starting to commission short and medium-term; not just here and now."
He adds that there is already good practice in joint working and commissioning between the sectors, predating recent legislative mandates. "The NHS IC can set joint health and social care data and commissioning into a national context, benchmark it, and give comparative data", he concludes. "With that, people can see other ways of doing things; other priorities in other areas; and ask themselves questions to ensure their commissioning is as good as it can be."
COMMISSIONING IN ACTION: South East Coast SHA stroke and dementia care
Marianne Griffiths, director of commissioning and delivery and deputy chief executive of South East Coast SHA, headed efforts to revolutionise care for dementia and stroke in the region by more effective information use.
"We recognised that trusts were often not using the right information to inform robust decision-making. So we invested in an information team to focus on turnaround, and on supporting organisations to ask the right business questions and giving them tools to diagnose problems.
"In an effort to focus on dementia and stroke care, which are sometimes utterly forgotten, we worked with The NHS IC on a project around dementia and stroke pathway. Dementia affects huge numbers, but is usually picked up too late so interventions aren't successful. Early diagnosis helps, so we worked with The NHS IC to really look at care pathways, and to clinically validate metrics.
"First, we took estimates of the number of patients on GP registers based on normal prevalence in the population, and found enormous variation across PCTs. Some recorded only 30 per cent of the prevalence you'd expect, but others 70 per cent.
"Then we looked at spending, for any correlation with prevalence and numbers on the GP registers, and found no consistent correlation. So we made a map and radar of the variables, with statistics for hospital and mental health admissions for dementia, and used these to pose questions for our PCTs".
Ms Griffiths describes The NHS IC's help as "really constructive and supportive, using their expertise to improve our enabling work. It's been a good symbiosis to improve outcomes for patients."
For more information on the NHS IC's Comparators product visit www.ic.nhs.uk