Jane Bethea and colleagues explain how a project at one trust helped to overcome many of the challenges commissioners face
Commissioners are under pressure to deliver high-quality care for the best price. They must set commissioning priorities appropriately and ensure that resources are in place to support these priorities.
Nottinghamshire County Teaching primary care trust has an established research and development team. Recently, its remit was expanded to include supporting evidence-based commissioning in the organisation. As part of this new area of work, it developed a research-based model that can be applied to many of the commissioning challenges faced by PCTs.
The team established that the model needed to include the following features:
the identification and use of existing best practice and research evidence;
the full engagement and involvement of key stakeholders;
active involvement of patients and service users.
Additionally, the model needed to be rigorous and transparent in its purpose, application and outcome.
Summary of the model
Phase 1: identifying evidence and best practice
The first phase is to search existing literature. This needs to go beyond the published research evidence and also consider high-quality service evaluation and examples of best practice. The work collected at this point needs to be critically appraised to determine quality and also the extent to which the findings and recommendations are locally applicable.
Phase 2: engaging with key stakeholders
The second phase involves engaging with key stakeholders, who might include clinicians, other service providers and patients. The overall purpose of this phase depends on the topic under consideration, but might be undertaken, for example, to identify the key components of an acceptable and deliverable service to meet a local health need. It could also be used to identify the benefits and challenges of new approaches to service design and delivery.
With this in mind, the research-based consensus methodologies lend themselves easily to this element of the model. There are several approaches to gaining consensus, but we propose the use of the Nominal Group Technique 2-4. As shown below, this is a highly structured process, which unlike some consensus approaches has a clearly defined input from participants. This is very important, as both health professionals and patients/service users are more likely to agree to participate if the time commitment is laid out clearly and is not considered too onerous.
Phase 3: identifying key features/components
Phase three involves drawing together the findings of phases one and two. For example, in a recent piece of work around the delivery of sexual health services for young people, we considered the key issues/features where consensus had been reached in phase two alongside the evidence collated in phase one. Through this, we were able to identify where there was evidence to support the service components considered by the key stakeholders as acceptable and important. However, it also allows components/features present in the literature but not identified by key stakeholders to be incorporated into potential models of service delivery.
Phase 4: engaging with service users
This phase involves working directly with service users chosen to represent the population who would access the service or be affected by the issue under review/development. Again, using the example of our work in the delivery of sexual health services, we worked with a local college and an agency working with unemployed young people to recruit young men and women under 25. We ran a series of focus groups where the young people were asked to consider the features/components identified in phase three. They identified which potential components of the service were acceptable and should be considered in the final model development.
Phase 5: final development and feedback phase
Phases one to four result in a list of service delivery components/features that are acceptable to key stakeholders and patients/service users and also supported with examples from the evidence base. This information can then be presented to commissioners to inform decision-making. How this information is delivered will depend on the subject matter, though in the example given above, we presented a series of potential models of sexual health service delivery that were developed directly through the application of phases one to four.
Taking this model forward requires a significant time commitment (the process may take three to four months) and has implications in terms of workforce development. To apply the model effectively staff need to have considerable research and/or complex evaluation skills.
However, the model also has clear benefits. One of the key strengths of the model it its ability to truly deliver research and development. It actively engages key stakeholders and patients/service users and can be applied to many issues faced by primary care commissioners. Finally, it allows an evidence-based approach to the development of services that address the specific needs of the local population.
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