Primary care is where the vast majority of NHS healthcare begins and ends, treating around nine out of ten patients and deploying around 60 per cent of the NHS's£100 million annual budget.
The policy driver to deliver more care in primary care is several years old now. It has been slowed by the ongoing absence of a community tariff. It has also been hampered by a lack of clarity about whether PCTs must give up their provider arms.
Yet despite these brakes on progress, the development of commissioning in primary care continues. Practice based commissioning is becoming embedded though, despite its name, is now almost uniformly done by consortia or clusters of practices.
Front-line views
Richard Popplewell, chief executive of Stockport PCT and a member of the SUS programme board, says that commissioners need "reliable, high-quality, accurate and timely data that is also accessible. That means suitable and adequate informatics tools with user-friendly presentation are needed, rather than just raw data." His PCT has used various products from The NHS Information Centre to assess its commissioning of treatments for cardiovascular disease (see below).
Mr Popplewell stresses that many data sets were developed to support business processes like payment and the managing and monitoring of targets, rather than for individuals' care. This presents challenges for the commissioning data sets flowing through SUS and individual patient records. He says: "The break might be too early. Although there's a lot in commissioning data sets in terms of volume, they're quite a crude summary of the care given to individuals, not very rich in clinical data.
"Commissioning data sets were largely driven by national epidemiology work, and then amended to serve business processes. We do seem to potentially compromise data sets to serve purposes for which they weren't originally derived. No doubt these compromises are widely understood, but we must remember they are compromises - rather than seeking commissioning data sets to monitor business processes and clinical care. They don't do both."
Emphasising the importance of using and stretching the data commissioners have now, Mr Popplewell says: "Don't get too worried about its inadequacy. By using it and finding inadequacies, it gets less inadequate in future iterations."
Pam Hughes, head of strategic performance at Western Cheshire PCT, adds: "Understand the data you've got, don't skim its surface. Drill down, and talk to your front-line staff to see what data they want and what data they need to help them: don't tell them what they can have. Once you understand down to data item level what you have and how you can marry it to other information, it can help you redesign, manage and deliver services".
CASE STUDY: Frontline commissioning
Richard Popplewell, chief executive of Stockport PCT, has used data from The NHS Information Centre to examine ways of delivering services to 290,000 residents. This population has relatively high rates of cardiovascular disease, he notes: "We are second or third highest in the country in terms of cardiovascular spend per head of population, but we have relatively poor outcomes."
Stockport PCT redesigned various pathways for cardiovascular patients, by comparing their activity and outcomes to the national average or various peer groups to see where underlying needs were not being met.
The Secondary Uses Service enabled the PCT to understand why their rates were so high. "It's absolutely vital to be able to compare yourself with other PCTs. You can't be complacent that you're doing all you can. There's always somebody somewhere doing better," says Mr Popplewell.
Also important to his commissioning is The NHS IC's Healthcare Resource Groups (HRG4). "Chief execs tend to pay attention to finance because if they don't they almost inevitably tend to get caught out at some stage," he said. Using this information helped the PCT deliver a£1.7 million surplus in 2007/08.
The PCT also finds The NHS IC's new NHS Comparators service useful in planning and monitoring services, and Mr Popplewell pays respect to his team of analysts: "We tend to draw a lot of information from SUS and then analyse and re-interpret it locally. What is particularly interesting is when you have patients flowing across pathways - hospital one to hospital two, particularly in cancer or chronic conditions, SUS is the only way you can do record linkage."
Iterative information and the 'first ask'
Sandra Hills, The NHS IC's director of commissioning, observed: "A major information challenge for primary care commissioning is that people in PBC consortia may not always be able to articulate the information problems they're trying to resolve, so it can be hard for us to identify what kind of information help they need. If they don't know what they don't know, it can be hard to signpost them to helpful information sources.
"One thing about using information is that you don't always get the answer the first time you ask the question, but sometimes the first asking helps you articulate the question you really need to ask more clearly. So the first ask becomes a basis of dialogue and clarification of question."
Ms Hills suggests that primary care commissioners should consider using The NHS IC's resources. "Commissioning starts with understanding population needs. We collect or have access to data on population size and demographics, lifestyle surveys on behaviours, and basic information on PCTs' coverage. There are also things about public health profiles and condition prevalence. All this can give a rich picture of the population of a PCT or PBC consortia - the people and patients for whom they provide care and commission services. It can give useful indicators of what services a healthy economy should look to provide."
Looking to the medium-term needs for commissioning, Ms Hills suggests more locally-based needs assessments, where PCTs will identify a particular area's needs where they want to see mortality and morbidity rates improving. "There will always be national and SHA-wide information needs to support commissioning, but there should also be local pockets relating to specific health needs for individual organisations."
World-class information
"Information skills and competencies are really important," Ms Hills concludes. "The NHS IC takes its role very seriously and sees its evolution and organisational development taking place in parallel to commissioning. As PCTs and PBC consortia are seeking to become world-class commissioners, so we're seeking to become a world-class organisation in relation to collecting, handling and securing information - and crucially, in presenting it in ways that effectively support and enable commissioners to do a good job."
Extracting GP data for commissioning
While the NHS has comprehensive, high-quality national data about hospital care, when it comes to primary care, its commissioners rely on local extractions which are not delivered in a standardised way.
This lack of nationally-coordinated information clearly hampers efforts to develop the best policies to tackle health inequalities and target resources in the most effective way.
However, all this is about to change with a new service being introduced by The NHS IC.
The General Practice Extraction Service will be a centrally managed data extraction and analysis service that will get information from NHS GP systems.
Dave Roberts leads on GPES for The NHS IC. He said: "Initially GPES is designed to meet national needs for information at GP practice level. But ultimately, at a later date, we may see NHS users in SHAs, PCTs and PBC groups.
"Currently the NHS can access a disparate range of primary care information sources. Some cover all practices, but extract only limited data. QMAS, for example, only holds information used to the support the quality and outcomes framework.
"Other sources, which are broader in scope, are all based on sample practices. This means their data is not appropriate for many purposes.
"GPES will deliver a joined-up approach which supports local commissioners, promotes better coverage for clinical audits and reduces the amount of time GPs and their practice staff need to spend on administrative burdens.
"It will also act as a focus for the development of clinical and data standards in primary care."
So will GPES data feed into commissioning?
"Absolutely. Our aim is to allow PCTs controlled access to the data they require. However, information governance and, in particular, patient confidentiality is paramount. GPES will operate under safeguards that are being discussed with the British Medical Association and the Royal College of GPs including appropriate opt-outs for GPs and patients.
"Phase One will incorporate these safeguards and work with GPs in order to minimise risks while delivering the huge benefits that aggregated information of this type can provide to the improvement of the health of populations and the delivery of NHS services.
"If we can achieve all that, we will allow PCTs in collaboration with GPs to produce information vital to the commissioning agenda such as developing care pathways as highlighted in the Darzi report, as well as improved public health surveillance."
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