There is still a chasm between the process of writing recommendations and the people responsible for commissioning the services to deliver them. Can world class commissioning bring these closer together, asks Martin Dougherty
For independent advisory groups, developing National Institute for Health and Clinical Excellence guidelines can have frustrations. One is that their carefully crafted evidence-based recommendations do not take into account the nature of the service that will deliver them. NICE is, after all, normally tasked with developing clinical guidelines, not service delivery.
But world class commissioning will mean robust clinical guidance should underpin both the range of services commissioned and the nature of contractual quality control between commissioner and service provider. A recent example is a guideline written by an independent advisory group at the National Collaborating Centre for Women's and Children's Health, which had the potential to offer greater choice and save costs but needed a change in service delivery to do so.
A fundamental right of consumers is access to a full range of sexual health services, enshrined in the 1994 International Conference on Population and Development. This means that consumers should be allowed choice of contraception. Meanwhile, there has been evidence that long-acting reversible contraception (LARC) has been much underused in the UK. It was also thought that access to this contraception within the health service was hugely variable. This led to the development of a NICE guideline for LARC, published in October 2005 by the National Collaborating Centre.
With thinking based around initiation and unit costs rather than cost-effectiveness, historically LARCs were considered rather expensive compared with the Pill. However, the guideline showed that all forms of LARC were more cost-effective than the Pill, even after only one year of use. Also, LARC combined with using the condom was more cost-effective than the condom alone, mostly because of imperfect use of condoms. An independent advisory guideline development group had discussed this evidence when making its recommendation to the NHS.
The group did not know whether GP practices would need more staff with training and competencies to initiate LARC to meet higher demand or whether the service would experience more local referrals to improve access. It was evident such issues would form a barrier to implementation of the LARC recommendations.
The group also realised a simple consultation followed by a prescription for oral contraceptive seemed a very easy option compared with initiating an LARC, particularly without any incentive.
It wanted to achieve greater choice for consumers and raise awareness among healthcare professionals. But because this was a clinical guideline, the group had no support from professional commissioners to help in thinking through the practical issues of configuring services to achieve their recommendations.
So 18 months after the guideline was published, an overall small net reduction in the prescription of all LARCs and an increase in prescribing costs was unexpected. A NICE implementation uptake report in August 2007 showed increased prescribing for certain types of LARC, but this was more than matched by a reduction in the prescribing of other types.
There was a net reduction in prescribing in primary care of nearly 3 per cent for all forms of LARC in the 12 months up to March 2007. Conversely, however, there was an apparent consumer preference for the more expensive forms of the contraception, leading to an overall increase in the costs of prescribing of 8.72 per cent.
Compared with an increase in the prescribing of the progesterone-only Pill of 11 per cent and a 30 per cent increase in budget requirement over the same period, it appears the market for LARC experienced internal product churn, rather than the market growth which would have given consumers additional contraceptive choice.
These changes could be related to consumers being more aware of the different types of LARC and changing their product preference after a marketing campaign from pharmaceutical companies. Observations based on national prescribing data should be cautious, however, as it is difficult to directly link cause with effect.
Yet these changes do highlight the need for additional data on consumer uptake rates and how rates are affected by the attitudes both of consumers and healthcare practitioners. This would support not just the clinical implementation of recommendations but also how services should be commissioned.
My belief that the LARC outcome was not a result of changes in commissioning strategy is backed up by the all-party parliamentary pro-choice and sexual health group, comprising both national professional and lay organisations. A survey of primary care trusts by the group reported in October 2007 that LARC provision was still patchy and not many had carried out service assessments.
This is surprising since the NICE national cost-impact report for LARC showed an expected saving to the NHS of£115m. To reach this, the recommendations would have to be effectively promoted and an 8 per cent increase in the uptake of LARC achieved. But in the end perhaps the biggest barrier to success was that the anticipated investment of£12.7m required to help establish effective services, which would then allow the switch from oral contraception to LARCs, has not happened. It could have given a tenfold return on investment.
Since the LARC guideline was published, the implementation team at NICE has made great headway in helping service providers plan for the cost impact of NICE guidance. A range of tools and support is available, including cost templates and audit criteria.
Perhaps even more important are the guides and tools aimed at commissioners. These help commissioners translate NICE guidance into what it means for their local populations. But there still appears to be a chasm between the process of writing NICE recommendations and the people who commission services to deliver these recommendations.
World class commissioning is an opportunity to strengthen the link between standards developed for healthcare and the way services are commissioned. Closer collaboration in translating clinical and cost-effectiveness data from NICE guidance into commissioning contract parameters may be critical.
Notably, several competencies from the world class commissioning framework lend themselves to improving this important relationship. It expects greater involvement of clinicians in strategy, quality, service design and resource usage. There is an expectation that commissioners should stimulate markets to ensure greater choice within locally provided services and that commissioning contracts have clear specifications linked to outcomes as indicators of service quality.
Much of the background evidence, along with effective pathways of care to achieve these requirements, is contained in the full versions of the guidelines developed by the national collaborating centres commissioned by NICE.
Under world class commissioning, I hope it will be possible to more strongly support a highly cost-effective recommendation such as the one for LARC. Service models that reward cost-effective interventions which improve consumer choice need to be a priority. Under world class commissioning it will be possible for commissioners to act as local investors in health who achieve the greatest health gains or reduction in health inequalities at best value. A return on investment would be a positive outcome.
For the LARC recommendation, local investment to commission the training required to allow the switch to it, combined with enhanced payment by results or quality outcome framework points to incentivise for prescribing or referring for its initiation, would be a good investment. Obviously the provision of contraceptives is just a small part of all services competing for scarce health resources and there will be a hierarchy driven by the local health economy. But specific cost savings, with improvement in clinical outcomes, alongside increased consumer choice, would seem an ideal target for the first wave of world class commissioning success stories.
And if the knowledge from NICE guidelines is to be fully integrated into the world class commissioning process, then perhaps NICE should recruit commissioners to the independent advisory groups that develop its clinical guidelines. Guideline developers would gain direct access to expert input on how clinical and cost-effectiveness recommendations can influence commissioning and service configuration. Then hopefully highly cost-effective recommendations may be supported by both commissioners and service providers alike.
Martin Dougherty is the executive director of the National Collaborating Centre for Women's and Children's Health.