The government’s vision for health service delivery is one of more diverse provision. Alternative providers are being encouraged to come forward, and the steer towards contestability in provision is matched by an emphasis on strong, intelligent and informed commissioning by primary care trusts.
The Care Services Improvement Partnership’s work with commissioners and NHS private and voluntary sector providers has highlighted the fact that we have a way to go to realise the government’s vision of a ‘managed market’ with plurality.
An enormous gap exists between NHS reform policy and its successful application. Huge swathes of NHS-commissioned services are still delivered by the NHS, but where more active markets exist, commissioners often struggle to ‘manage’ them to meet local need.
Commissioners and non-NHS service providers in the North West told CSIP they would value practical support in applying guidance. A pilot was designed with this in mind and rolled out in East Lancashire - an area with significant complexities.
About the area
East Lancashire is one of the most deprived areas in the country;
it has significant associated health inequalities (spearhead primary care trust status);
there is a large concentration of diverse minority groups;
much private sector housing is poor.
The PCT budget is£500m with 10 per cent spent on mental health;
Lancashire county council also spends£1.2m;
there is a diverse mix of mental health nursing/care homes and supported accommodation;
mainly private and voluntary sector provision.
Growth was previously led by providers' perceptions of need;
importing people to fill vacant beds;
mixed views of quality;
no history of collaborative working between providers;
placements poorly managed;
people placed in services with limited follow-up or monitoring.
The potential benefits of applying a whole-system approach to services in East Lancashire were enormous. To achieve the necessary changes, a sensitive approach was required to get providers on board, while also getting across the message that service quality and active participation in the system were needed if they wanted to develop a long-term working relationship.
The project ran for seven months and used a range of methods to build a full picture of the needs of people placed in the services, quality of provision and links with care programme approach care co-ordinators.
User need was identified by triangulating the views of providers, care co-ordinators and independent reviews carried out by two clinicians from Lancashire Care trust seconded to the project. Throughout the process, providers participated in designing the methods used, provided views on user needs and also the quality of their own services.
The second element of the project assessed the quality of services. A purpose-designed quality assessment tool was developed. Providers helped develop the tool and completed self-assessments before visits by CSIP reviewers, who completed the QA assessment at the end of the visit. Views of reviewers and providers were compared and a shared understanding of the rating was agreed. Where differences could not be overcome, both views were presented to commissioners.
Before this, the definition of ‘quality’ was variable. Bringing providers and commissioners together in designing the QA tool helped develop a shared understanding based on user wishes, aspirations and promoting choice. After the reviews, services were able to produce a development plan quickly, based on those areas where their scores were weak. These plans are being used as the basis for service development and contract-monitoring meetings between providers and commissioners while the process of managing the market is implemented.
The data was presented to providers, care programme approach care co-ordinators and community mental health team managers. This allowed them to query findings, find solutions to problems and directly input into the report drafted by CSIP to manage the market. The commissioners are now using this as the basis of their strategic plan to implement change and to co-ordinate the whole-system approach.
The process is slow and requires dedicated time and tenacity.
It needs to be commissioner-led with dedicated resources, particularly when implementing the strategy.
A range of contracting models are needed and link to quality of service provision and commissioner need.
Strategic oversight of providers is not the role of case managers and needs systems in place managed by commissioners to achieve successfully.
By regularly spending time together, providers and commissioners can build an effective working relationship. This works best if based on shared tasks.
Commissioners and regulators can be distant and need mechanisms for sharing concerns about providers with each other.
The user voice in private-sector services is not well established and needs proactive development led by commissioners.
Without effective advocacy, people using services are denied the opportunity to participate in developing quality services. Services that proactively listen to their users stand a better chance of continually improving.
Advocacy services require clear commissioning to be proactively involved in independent-sector services.
Commissioning for outcomes should follow the process of market management. This can be time consuming in contrast to commissioning for activity and volume but is a more effective use of resources for both users and commissioners.
All placements are known to commissioners.
Clear reporting mechanisms have been established between providers, care programme approach care co-ordinators and commissioners.
Contracts are being reviewed and revised.
Contract monitoring meetings have been established that also examine service development.
A provider forum has been established which is working on care pathways, quality initiatives and shared staff training and development - this is commissioner-led and driven.
Everyone knows where they stand.
Users are getting a better service.
If increased plurality in service provision is to result in substantively better services and more choice, commissioners and service providers from the public, private and voluntary sectors need support to work together.
Commissioners must be supported to manage increased market forces with a constant view of the needs of the population they serve. They need a clear understanding of how each provider is different and adds value to their local market. Collaboration in ‘contested’ systems stands a better chance of delivering improved health outcomes than competition for the sake of it.
Tony Ryan is an associate consultant at CSIP North West. Louise Edwards is a senior consultant in commissioning and system reform. Frank Hanily is head of joint mental health commissioning at East Lancashire PCT.